



r^^M^^^^mm 



Diseases of the Lungs 



A. L BLACKWOOD, M. D. 



PROFESSOR OF GENERAL MEDICINE AND SENIOR PROFES- 
SOR OF PHYSIOLOGY IN THE HAHNEMANN MEDICAL 
COLLEGE, CHICAGO; ATTENDING PHYSICIAN TO 
THE HAHNEMANN HOSPITAL, CHICAGO; 
ASSOCIATE PHYSICIAN TO COOK COUNTY 
HOSPITAL; MEMBER OF THE AMER- 
ICAN INSTITUTE OF HOMEO- 
PATHY, ILLINOIS STATE 
HOMEOPATHIC SOCIETY; 
AUTHOR OF .DIS> 
EASES OF THE 
HEART, ETC. 



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HALSEY BROS. 


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CHICAGO 


AND ST. 

1902. 


PAUL. 






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THE LIBRARY OF 
CONGRESS, 

T««D CowE? Received 

JUN. 18 1902 

COPVRIGHT ENT«»v 

CLASS ^XXC No. 
COPY B. 



COPYRIGHT 1902 

BY 
A. L. BLACKWOOD. 



PREFACE 

The author has endeavored to present the saHent 
points in the etiology, pathology, symptoms, diag- 
nosis, prognosis, and treatment of diseases of the 
lungs in as brief and practical a manner as possible. 
Speculative and unimportant theories have been 
avoided, while practical and clinical facts have been 
presented. Special attention has been devoted to 
the subject of treatment, general management of 
the case and the indication for the various remedies, 
the latter being presented in the order of their im- 
portance as observed by the author. Under differ- 
ential diagnosis, tables have been prepared to render 
the important differentiating points perceptible at a 
glance. The primary object of the work has been 
a presentation of those facts that are of service in 
the recognition and relief of pulmonary diseases. 
The growing importance of these topics, as a result 
of the increase in pulmonary affections, suggests the 
need of a more thorough knowledge of the various 
diseases to which these organs are liable, and this 
work is presented to the profession in the hope that 
it may stim.ulate a more thorough investigation of 
these subjects. 

J I Was king to ft Street, Chicago, 

May First, Nineteen Hu?idred a7id Two. 



CONTENTS. 



CHAPTER I. 

The Lungs: Their Relation to the Chest Wall and Surrounding 

Organs 1 

CHAPTER n. 
The Clinical Examination of the Patient : Semeiology 3 

CHAPTER HI. 
Pathology . 21 

CHAPTER IV. 
Therapeutics 27 

CHAPTER V. 

Diseases of the Trachea : 

Acute Tracheitis 33 

Chronic Tracheitis 35 

Diphtheria 36 

Tuberculosis of the Trachea 37 

New Growths of the Trachea 37 

Stenosis of the Trachea 38 

Perforation of the Trachea 39 

CHAPTER VI. 
Acute Bronchitis of the Larger Tubes 40 

CHAPTER VII. 

Acute Bronchitis of the Smaller Tubes - 52 

CHAPTER VIII. 
Chronic Broncliitis 59 

CHAPTER IX. 

Fibrinous Bronchitis 76 

Bronchial Stenosis 80 

CHAPTER X. 

Bronchiectasis 83 

Atelectasis 88 

CHAPTER XL 

Vesicular Emphysema 92 

Senile Emphysema 100 

Compensatory Emphysema 100 

Interstitial or Lobular Emphysema 101 

Bronchial Concretions 102 

Bronchial Flukes 102 

CHAPTER XII. 
Asthma 104 



Vlll CONTENTS. 



CHAPTER XIII. 

Hay Asthma 116 

Hemoptysis 121 

CHAPTER XIV. 
Broncho-Pneumonia 128 

CHAPTER XV. 
Croupous Pneumonia 138 

CHAPTER XVI. 

Acute Congestion of the Lungs 163 

Edema of the Lungs 166 

CHAPTER XVII. 

Puhnonary Fibrosis 171 

Hypostatic Hyperemia 175 

Passive. Hyperemia 177 

CHAPTER XVIII. 

Pulmonary Infarction 179 

Abscess of the Lung 181 

Gangrene of the Lungs 184 

CHAPTER XIX. 

Pneumokoniosis 188 

Pulmonary Actinomycosis 191 

Hydatids of the Lungs 193 

CHAPTER XX. 

Pulmonary Mycosis 195 

Pulmonary Complications of Acute Diseases 196 

Pulmonary Anemia 197 

Tumors of the Lungs 197 

Syphilis of the Lungs 199 

CHAPTER XXI. 

Pleurisy 203 

Fibrinous Pleurisy 203 

CHAPTER XXII. 
Sero-Fibrinous Pleurisy 209 

CHAPTER XXIII. 

Diaphragmatic Pleurisy 219 

Tubercular Pleurisy 221 

Chronic Pleurisy 222 

Chronic Dry Pleurisy 222 

Chronic Pleurisy with Effusion 224 

CHAPTER XXIV. 
Empyema 227 

CHAPTER XXV. 
Pneumothorax 236 



CONTENTS. IX 



CHAPTER XXVI. 

Hemothorax 244 

Hydrothorax 245 

Chylothorax 247 

New Growths of the Pleura 249 

CHAPTER XXVII. 

Pulmonary Tuberculosis 251 

Physical Signs of the Incipient Stage ■- 267 

Second Stage, or Stage of Consolidation 268 

Third Stage, or Period of the Formation of Cavities 269 

CHAPTER XXVIII. 

Pulmonary Tuberculosis (continued) 275 

CHAPTER XXIX. 

Acute Pulmonary Tuberculosis 300 

Acute Miliary Tuberculosis 304 

Fibroid Tuberculosis 308 

CHAPTER XXX. 

Pleurodynia 311 

Affections of the Diaphragm 314 

Osseous Complications 316 

CHAPTER XXXI. 

Diseases of the Bronchial Glands 318 

Tumors of the Mediastinum 322 



I 



CHAPTER I. 
THE LUNGS, 

Their Relation to the Chest Wall, and Surrounding Orgfans* 



The lungs occup}' the greater part of the thora- 
cic cavit}^, and are separated by the structure found 
in the mediastinal space. The outer surface of 
each lung is convex, and adapted to the inner sur- 
face of the chest wall. The inner surface is con- 
cave to receive the mediastinal structure, while their 
bases are in contact with the diaphragm. The left 
lung extends one inch and a half to two inches above 
the first rib, while its lower anterior border is in 
the meso-sternal line from the level of the second 
to the fourth costal cartilage, at which point it 
leaves this line, and the inferior border is found 'at 
the sixth rib, in the mammillary line, at the eighth 
rib in the mid-axillary line, and at the tenth rib in 
the scapular line. The apex of the right lung does not 
extend more than one inch to an inch and a half above 
the first rib; its anterior border is at the meso-ster- 
nal line, from the second to the sixth costal carti- 
lage; its inferior border is at the sixth rib in the 
mammillary line, at the eighth rib in the mid-axil- 
lary line, arid at the tenth rib in the scapular line. 

The inferior border of the lung is depressed an 
inch and a half upon deep inspiration; the left one 
being the lower of the two in the scapular and mid- 
axillar}^ region. 

The left lung has one fissure that divides it into 
two lobes. It starts about three inches below the 
apex of the lung near the vertebral column and ex- 



THE LUNGS. 



tends downward and forward, being at the fourth 
rib in the mid-axillary line, and the sixth in the mam- 
millary line. The upper lobe reaches from the apex 
to the lower margin of the lung anteriorly and is 
above the fourth rib posteriorly, while the lower 
lobe reaches from the fourth rib to the lower mar- 
gin of the lung posteriori}^ 

The right lung has a long and a short fissure. 
The long fissure separates the lower lobe from the 
middle and upper lobes. It extends from near the 
vertebral column about three inches below the apex 
of the lung, downward and forward, being at the 
fourth rib in the mid-axillary line, and at the sixth 
rib in the mammillary line. The lesser fissure 
separates the middle from the upper lobe, and 
extends from the long fissure, near the anterior 
border of the scapula, downward and forward; its 
direction being from beneath the third intercostal 
space. It cuts the anterior border of the lung at 
the fourth costal cartilage. 



CHAPTER II. 
THE CLINICAL EXAMINATION 

of the Patient ; Semeiology. 



In order to make a systematic examination of 
the chest all clothing should be removed from the 
upper portion of the body, and the whole of the 
thorax carefully gone over, not merely the portion 
to which the disease is supposed to be confined. 
In accomplishing this task practice has shown that 
it is advisable to follow the established rule and 
conduct it under the headings of inspection, palpa- 
tion, percussion, auscultation, and in some cases 
mensuration, alteration of the patient's position, and 
Hypodermic exploration. The patient should occupy 
such a position that a good light is thrown upon 
the chest. 

Inspection: — The color and condition of the 
cutaneous surface and mucous membrane should be 
observed. When cyanosis is present there is a 
greyish-blue tint noticed about the face, lips and 
finger nails. This varies in degree from a slight 
purplish tint, up to the grey-blue color of the 
advanced cases of cardiac and pulmonary disease. 
When cyanosis is copibined with pallor, it produces 
an ashy-grey tint. This is seen in connection 
with the following pulmonary diseases: phthisis, 
asthma, pneumonia, and emphysema, as well as in 
various cardiac lesions. Pallor should always lead 
to a careful examination of the case, for, when of 
the mucous membrane, it is a sign of anemia, 
which is one of the symptoms of tuberculosis. 



THE CLINICAL EXAMINATION. 



Jaundice, when present in pulmonary disease 
accompanied by fever, should lead one to think of 
pneumonia. 

Eruptions and scars should lead to a careful 
inquiry as to the presence of syphilis, as these 
secondary manifestations may point to an involve- 
ment of the lungs and bronchi. 

Glandular enlargement about the neck and axilla 
is suggestive of pulmonary tuberculosis, malignant 
disease, syphilis, and '' Hodgkins disease," while an 
enlargement of the thyroid gland ma}^ give rise to 
dyspnea. 

The nutrition of the patient should be observed 
as indicated by the fatty deposits, muscular develop- 
ments, and color, as well as by the emaciation as 
seen in the prominent ribs, winged scapulae and 
projecting clavicles. 

The size of the chest should be noticed. Its 
circumference is small when compared with the ver- 
tical diameter in those who have been confined to 
bed for a long time, or have suffered during child- 
hood from rickets, or disease of the naso-pharynx, 
while it is enlarged in cases of emphysema. 

The form of the chest is to be observed. It 
should be remembered that during childhood the 
chest is nearly cylindrical, while in adults there is 
a distinct flattening in the antero-posterior diameter. 
The normal contour of the chest wall may be 
broken by local bulgings, as abcesses, periostitis, 
malignant growths, or deformities of the chest wall. 
As a result of disease of the lung or pleura one 
side may be enlarged, as in cases of tumors, accu- 
mulations of fluid or gas in the pleural cavity; or 



THE CLINICAL EXAMINATION. 



it may be smaller, the result of retractions due to 
phthisis or fibroid induration. 

The conditions that result in deformity of the 
chest wall are principally rickets during childhood; 
emphysema, phthisis and disease of the pleura later 
in life. 

The pigeon breast is characterized by a promi- 
nence of the lower portion of the sternum and a 
straightening of the true ribs, resulting in a flatten- 
ing of the thoracic walls. 

In the rachitic chest there are thickenings at the 
costo-chondral articulations that are spoken of as the 
rachitic rosary. 

In the funnel breast there is a coiigenital 
depression of the lower end of the sternum, which 
is also seen in shoemakers, being then due to 
pressure. 

The barrel chest is seen in cases of emphysema, 
in which the anterior-posterior diameter is increased, 
the shoulders are high, the neck shortened and the 
intercostal spaces are wide and full. 

The altar chest is narrow, with sloping shoulders, 
wing-like scapulae, and is thought to favor tubercu- 
losis. Harrison's groove is a depression that 
extends from the ensiform cartilage outward toward 
the axilla; corresponding to the attachment of the 
diaphragm. It is observed in cases where powerful 
action of the diaphragm is demanded, as in inspira- 
tory dyspnea. 

The spinal column should be examined for 
abnormal curvatures which may be the result of 
pathological conditions or defective developments. 
The posture of the patient should be carefully 
observed. A drooping position indicates weakness 



THE CLINICAL EXAMINATION. 



and exhaustion. There is a desire to lie upon the 
painful side during the early stages of pleurisy, but 
when effusion has taken place a change from the 
inflamed side is made. In certain pulmonary dis- 
eases, such as asthma, edema, etc., the patient 
cannot lie down. 

The movements of the chest should be observed 
to ascertain if it expands equally upon both sides; 
any variations from this should be carefully noted. 

The respiratory movements differ in the sexes 
and in children. In the female, the movements 
are most marked in the upper portion of the chest 
and are spoken of as superior-costal; in males, they 
are most marked in the lower portion of the chest 
and are said to be inferior-costal; while in children 
they are most marked in the abdomen, and the 
breathing is said to be diaphragmatic. In normal 
conditions the chest expands equally upon both 
sides with a slight depression of the intercostal 
spaces during inspiration. 

Inspiration should bear the relation to expiration 
that six does to seven, with no pause between them. 
The rapidity of the respirations varies according to 
the age, and to the physical and mental conditions; 
under one year they are about 40 to the minute; 
there is a gradual decrease up to one year of age, 
at which time the}^ are about 30 to the minute; 
when the twentieth year is reached they are down 
to 20 to the minute; and by the thirtieth year they 
are 16 per minute; after this period thej niay 
be slightly increased. The position of the body, 
exercise, conditions of the atmosphere, heat, and 
mental states all modify the number of respira- 
tions. 



THE CLINICAL EXAMINATION. 



The intercostal spaces are seen to bulge during 
expiration in cases of emphysema, while retraction 
of the soft parts occurs during inspiration when 
there is obstruction in the upper passages; as in 
croup and paralysis of the vocal cords. An increase 
in number of respirations (hyperpnea) is present 
during fever, and in those conditions that lessen the 
aerating capacit}^ of the lung, as emphysema, 
edema, pneumonia, disease of the pleura in which 
the lung is compressed, disease of the abdominal 
organs that press upon the diaphragm, such diseases 
of the heart as affect the pulmonary circulation, and 
all those diseases that result in narrowing of the 
bronchi, or that cause painful respiration. 

Slow respirations are seen in certain diseases of 
the brain and meninges; in cases of acute infectious 
diseases where there are mental dullness, and Cheyne- 
Stokes respiration, but in none that are wholly 
dependent upon the lungs. 

Dyspnea is a term applied to a rapid, deep, or 
difficult breathing. When inspiratory in character 
it is usually the result of interference with the 
ingress of air, or paralysis of the diaphragm. 
When expiratory it is usually the result of asthma, 
or emphysema. A mixed form is present in many 
pulmonary diseases. An exaggerated form known 
as orthopnea is met with in severe cases of asthma 
and cardiac disease. 

The Cheyne-Stokes breathing is a condition in 
which a short recurrent paroxysm of dyspnea is 
preceded, and followed, by a period of apnea [no 
breath]. This period of apnea may last for ten 
seconds when the respirations begin, short and shal- 
low at first, but gradually increasing in rate and 



THE CLINICAL EXAMINATION. 



volume until a marked dyspnea is reached, when 
there is a gradual return to the state of apnea. 
The cycle may take from 35 to 70 seconds. Dur- 
ing the period of apnea the pupils are contracted 
and consciousness may be lost. This form of 
breathing is most frequently seen in cases of car- 
diac, renal, and cerebral disease. In many cases it 
is an unfavorable sign, and yet cases are met with 
in which it is present for years before death. 

The causes of dyspnea are many: it may result 
from a deficiency of air passing to the lungs, which 
may be dependent upon muscular weakness; pain 
about the chest; anchylosis of the articulations of 
the thorax; bony malformations; diminution in the 
caliber of the bronchial tubes; a lessened capacity 
of the lungs as is seen in pneumonia, pleural effu- 
sion, edema, etc. A modification of the air inhaled 
and a diminution of the quantity of blood aerated 
are also occasional causes. 

Catchy or restrained breathing is observed in 
pleurodynia, intercostal neuralgia, pleurisy, and 
pneumonia and may be accompanied with a grunt 
or a moan. 

Shallow and irregular breathing is seen in cases 
of unconsciousness, as in apoplexy and poisoning. 

A sighing, shallow breathing is observed after 
severe hemorrhage. 

A high pitched, stridulous breathing is noticed 
in cases where there is an obstruction at, or near 
the glottis; as in cases of edema, croup, foreign 
bodies, and tumors about the larynx. 

Diaphragmatic movements (Litten's sign may 
be observed in some patients by placing them upon 
the back with their chest bared and having the 



THE CLINICAL EXAMINATION. 



feet pointing toward a window where there are no 
cross Hghts. As the patient takes a full deep breath, 
a short, narrow shadow is seen to move from the 
seventh. to the ninth or tenth rib in the Hne of the 
axilla, and during expiration it moves back. This 
is due to the peeling of the diaphragm from the 
chest wall as the lung descends. It is not seen in 
cases of pleuritic effusion, adhesion, or emphysema. 
Palpation: — This is the method of physical 
examination accomplished by the laying of the 
hands upon the surface of the body. It gives much 
information as regards the size, shape, and consis- 
tency of a part, whether it is moist or dry, hot or 
cold. It also locates painful points upon the sur- 
face, defines their area, designates whether they are 
superficial or deep, and confirms inspection in regard 
to muscular and respiratory movements. But the 
principal information it communicates is by fremitus. 
Tactile fremitus is the name given to a sense of 
vibration that is communicated to the hands as the 
patient repeats some short word or phrase, as 
''ninety-nine" or "one, two, three." This is also 
spoken of as vocal fremitus, voice fremitus, vocal 
vibrations, or pectoral fremitus. It is greater in 
those having low-pitched, strong voices; and, as a 
result, is more marked in men than in women, and in 
adults than in children. Owins: to the size and 
direction of the bronchi it is more marked over the 
apex of the right, than over the apex of the left 
lung; and in those with thin chest walls, than in 
those who are fat or have great muscular develop- 
ment. It is increased over consolidation, as in cases 
of pneumonia and phthisis, so long as a medium 
sized or large bronchial tube remains patulous; also 



lO THE CLINICAL EXAMINATION. 

in cases of collapsed lung above the line of the 
effusion, and over cavities that have dense walls 
and communicate with large bronchial tubes. It is 
diminished where the pleural space is filled with 
fluid, as in pleuris}', and hydrothorax; or is . filled 
with air in pneumothorax, and emphysema; or with 
solids, as in new growths, thickening of the pkura, 
or in cases where the bronchial tubes are 
obstructed. Pleural friction may be recognized by 
palpation at the lower portion of the axilla where 
the costal and diaphragmatic layers of the pleura 
are in opposition. Rales may be recognized at 
times, when they are of the coarse, dry variety. 
Tussive fremitus is produced when the patient 
coughs, and is of service to the diagnostician when 
the voice, for any reason, cannot be called into use. 
The cardiac impulse should be palpated as it is 
displaced in cases of pleural effusion, pneumothorax, 
and fibroid induration of the lung. 

Percussion: — This is the method, in physical 
examination, of eliciting sounds, and estimating den- 
sity, by striking the part. 

Methods: — These may be either immediate or 
mediate. In the former the chest is struck directly 
with the fingers, or plexor, without any intervening 
pleximeter; while in the latter the blow is upon a 
pleximeter. 

The most useful instruments to be used for 
plexor and pleximeter are the fingers. The middle 
finger of the left hand is placed firmly upon the 
parts, while the other fingers of the hand are 
slightly raised that they may not interfere with the 
vibrations; with the second finger of the right hand 
strike a quick, perpendicular and rebounding blow 



THE CLINICAL EXAMINATION. II 

upon the middle finger of the left, just behind the nail. 
When comparing the resonance of different parts, 
the blow should be of uniform force; the motion 
should be from the wrist and never from the elbow. 
The plexor finger should be bent at right angles, 
and the direction of the blow should be perpendicu- 
lar to the pleximeter finger. The force used in per- 
cussion must depend upon the purpose of the per- 
cussion, the organs examined, and the thickness of 
the chest wall. 

During percussion all clothing should be removed 
from the chest, and the arms kept in a symmetri- 
cal position. When examining the front of the 
chest, the arms should be by the side; when exam- 
ining the back, they should be folded across the 
chest, and the body bent forward; when the sides 
are examined, have the patient cross the arms over 
the head. During the examination, the patient may 
occupy any position so long as the muscular tension 
is equal upon both sides of the body. The examiner 
should have such a position that the ear is the 
same distance from the parts percussed. The two 
sides should be in a like stage of respiration when 
the resonance is compared. During percussion it is 
necessary to bear in mind a few of the leading 
elements of sound: 

Quality is the property that distinguishes one 
sound from another. 

Intensity is the loudness or distance at which it 
is heard. 

Duration is the time during which it is heard. 

Pitch is its position in the musical scale, and 
bears a relation to both duration and intensity, so 
that the higher the pitch, the shorter the duration, 



12 THE CLINICAL EXAMINATION. 

and the less the intensity; the lower the pitch, the 
longer the duration and the greater the intensity. 

Normal pulmonary resonance is obtained over 
both lungs, except at those points where they over- 
lap the heart, liver, spleen, or are covered by the 
scapulae. The pulmonary resonance is less intense, 
and of a higher pitch, over the right apex than over 
the left. The cause of the normal vesicular reso- 
nance is supposed to be due to the combined vibra- 
tions of the chest walls, bronchi, alveoli, and the 
air contained in them, modified by the thickness of 
the chest walls and the bon}^ framework. It is soft 
in quality, of a low pitch, w^ith great intensity, and 
of long duration. It will vary at a given location 
with the degree of respiratory expansion, the amount 
of lung under the part percussed, and the thickness 
of the chest wall. 

An exaggerated resonance is observed in cases 
of emphysema, anemia, and in those cases w^here 
there is a part of, or a whole lung, disabled; thus 
causing an over distension with air, of the remain- 
ing pulmonary tissue. This is spoken of as hyper- 
resonance, or compensating emphysema. Dullness is 
a diminished resonance in which there is less air, or 
more solidity, under the part percussed. It may 
be vesicular or tympanitic in character. The former 
is noticed where the lung overlaps the heart, liver, 
and spleen; where there is a thickening of the chest 
wall, the result of edema or inflammation; in cases 
where there is deposited in the pleural space a thin 
layer of fluid or inflammatory exudate; or where 
there is but a moderate amount of consolidation of 
the lung as is met with in pneumonia, tuberculosis, 



THE CLINICAL EXAMINATION. 1 3 

syphilis, pulmonary hemorrhage, edema or atelec- 
tasis. 

The tympanitic dullness is heard over the lower 
portion of the liver, heart and spleen, when the 
colon or stomach is distended with gas. 

Flatness is the term applied to the note received 
when percussion is made over the organs that con- 
tain no air. The quality of the note is hard and 
non-resonant and is termed the "thigh sound,'' per- 
cussion over the thigh being taken as typical; in 
pitch it is the highest of all percussion notes, while 
in duration it is the shortest. It is heard, normally, 
over the uncovered portion of the liver, heart and 
spleen, and in cases of pleurisy with effusion, 
emphysema and hydrothorax. 

A tympanitic resonance is normal over the colon 
and stomach, when they are distended with gas. 
It is also heard over the chest in cases of pneumo- 
thorax, bronchiectasis and in an area of pulmonary 
consolidation, over the trachea. When the note is 
obtained by percussion over a closed cavity it is 
spoken of as closed tympany. The open tympany 
resonance is from cavities having an opening; the 
resonance may be amphoric or cracked metal 
resonance. The amphoric is obtained over cavities 
having a large opening communicating with the 
bronchus as in cases of pneumothorax. It mav be 
imitated by percussing the trachea, or the cheek 
when it is distended with air, and is compared to 
the ringing hollow sound produced by blowing 
across the mouth of a bottle. The cracked pot 
resonance may be heard over normal chests, during 
percussion, when there is much hair upon the body, 
if the pleximeter is loosely applied in an adult 



14 THE CLINICAL EXAMINATION. 

when singing a prolonged note, or in children when 
crying. It is heard in some cases where there is a 
pulmonary cavity communicating with a bronchus 
by a small opening; to obtain it the percussion 
should be firm and the mouth open. It may be 
heard during the stage of engorgement in pneumo- 
nia, above the line of effusion in pleurisy, and 
when there is an opening through the chest wall 
to the pleural cavity. It may be closely imi- 
tated by clasping the hands, palm to palm, and 
striking the under hand hard upon the knee, when 
a sound, "chinking" in quality is produced. 

"Lung reflex." In some cases of percussion 
dullness it will be found that if forcible percussion is 
continued for a time, the percussion resonance is 
increased. The sense of resistance should always 
be noticed while percussing a part. 

A uscultation : — This is the art of listening to 
sound generated within the body. It may be 
practiced by placing the ear directly against the 
chest wall, and is known as immediate or direct 
auscultation; or by the assistance of a stethoscope, 
which is mediate or indirect auscultation. The 
physician should be proficient in both. 

The patient's chest should be bared for mediate 
auscultation, and covered with a single layer of 
clothing. His position should be an easy symmet- 
rical one, that there may be as little muscular ten- 
sion as possible. The room and surroundings should 
be free from noises. 

The elements of sound mentioned under percus- 
sion are to be remembered in auscultation with the 
addition of rhythm, which is the relation that 
sounds bear to one another in time. 



THE CLINICAL EXAMINATION. 1 5 

Normal breathing should be carefully studied 
that the variations from it may be recognized. 
Normal vesicular breathing is the sound heard over 
the parenchyma of the healthy lung, and is most 
typical over the infra-scapular regions. The cause 
of the sound has been variously attributed to the 
entrance of the air into the alveola and the vibra- 
tion produced thereby, and that produced by the 
glottis, modified by the lung tissue. During inspi- 
ration it is soft and breezy in quality, and of a low- 
pitch, while its intensity and duration vary. The 
expiratory sound is less vesicular, of a lower pitch, 
with a variable intensity, but of a shorter duration 
than inspiration. 

Tracheal and bronchial breathing are heard over 
the trachea and bronchi, and differ but little from 
one another. They are tubular or blowing in qua- 
lity, of a high pitch, with great intensity; inspira- 
tion and expiration being of about equal length. 

The bronchial breathing is heard normally over 
the trachea; and over consolidated lung tissue, in 
pneumonia and phthisis, when the bronchial tubes 
are patulous. 

Cavernous breathing has a soft, blowing, or puffing 
quality, with low pitch, variable in intensity and 
duration. It is heard over pulmonary cavities, with 
a wall that collapses and expands easily upon inspi- 
ration and expiration. 

In broncho-cavernous breathing both the bron- 
chial and cavernous sounds are heard, and are pro- 
duced by a cavity surrounded by an area of con- 
solidated lung, as is found in phthisis, abscesses, 
and gangrene. 

Vesicular cavernous breathing is heard where 



l6 THE CLINICAL EXAMINATION. 



there is a cavity surrounded with nearly normal 
tissue. 

In amphoric breathing the quality is hollow, 
musical or metallic. It is heard best during inspi- 
ration, and over cavities with firm walls. It is the 
result of the passage of the air in and out, or over, 
the opening to the cavity. 

The respiratory sounds are increased in children, 
due to the thinness and elasticity of the chest wall; 
and in those cases where a portion of a lung, or a 
whole lung, is performing more than its normal 
work, as in consolidation, atelectasis, or any condi- 
tion that renders a whole lung or a portion of it 
inactive. 

The respiratory sounds are diminished over the 
chest of those with great muscular development, 
when an excess of adipose tissue is bound over the 
scapule, in cases of superficial breathing. Normally 
it is less distinct over the right lung. They may 
result from pathological conditions when the chest 
wall is thickened from an}^ cause, as edema, inflam- 
mation; or where the pleura is diseased. They are 
diminished in cases of emphysema, pulmonary edema, 
and in all those cases where there is a stoppage to 
the air entering the alveoli, as well as in cases of 
paralysis of the diaphragm, and any interference with 
the expansion of the lung, as is seen in ascites, tym- 
pan}', and also in those cases where respiration is 
attended with much pain, as in pleurisy, pleuro- 
dynia, etc. 

The respiratory sounds are totally suppressed in 
cases of pneumo-thorax, hydro-thorax, empyema, 
pleurisy with effusion, and where the larger tubes 
are completely obstructed. 



TiiE CLINICAL EXAMINATION. 1 7 

The inspiratory sound is shortened in cases of 
emphysema, in which the inspiratory act begins 
before the sound, and in cases of pulmonary consol- 
idation in which the inspiratory sound ceases before 
the act. 

The expiratory sound is prolonged normally over 
the apex of the right lung and at times over the 
left. It is heard in pathological conditions over a 
consolidated lung, also in_ cases of asthma and 
emphysema. 

Vocal resonance is the voice sound heard over 
the chest. In males it is usually heard over the 
whole chest, while in females and children it is 
heard best over the upper portion of the chest, 
being less distinct over the lower portion. It is 
exaggerated in cases where there is consolidation 
of the lungs as in pneumonia and phthisis. It is 
diminished in those cases where the transmission of 
the air sounds are interfered with as in closure of 
the bronchi, and disease of the pleura that leads to 
effusion and thickening. 

Bronchophony is a sound of variable intensity 
that is characterized by a concentration of the 
human voice. It is constantly heard over a main 
bronchus, and over consolidated lung tissue in pneu- 
monia and phthisis, above the line of fluid in cases 
of pleurisy, and over a cavity having a dense wall 
and surrounded with consolidated lung tissue. 

^gophony and pectoriloquy are variations of bron- 
chophony. ^Egophony is so called because the 
nasal or bleating character of the sound resembles 
the bleating of a goat. It is heard over consoli- 
dated lung tissue covered with a thin layer of fluid, 
as in cases of pleuro-pneumonia. 



I^ THE CLINICAL EXAMINATION. 

Pectoriloquy is a modification of bronchophony 
in which the articulate speech is audible over con- 
solidated lung, as in cases of phthisis and pneumo- 
nia; and over a large opening in the lung, as in 
cases of abscesses and bronchiectasis. The whisper- 
ing sounds correspond very much to those of the 
breath sounds. 

The cough of the patient should be carefully 
studied, especially as to its cause, which ma\' be a 
cold draught upon the surface of the body, an 
irritation of the auditory canal or nares. disease of 
the soft palate, pharynx, larynx, trachea, bronchi, 
pleura or stomach. 

The laryngeal cough is spasmodic and hacking 
in character, while the bronchial cough is modified 
by the character and amount of the bronchial se- 
cretions. If there is but little secretion, the cough 
is tight and harsh : while if there is much secre- 
tion, it is loose and rattling. In some cases it is 
attended with more or less soreness along the lines 
of the attachment of the diaphragm, and distress 
under the sternum. A cavernous cough has a hol- 
low quality, while an amphoric cough has a pecu- 
liar sound such as is heard in blowing across the 
neck of a bottle- 

Rales are sounds produced by the passage of 
air through fluid within the alveoli and bronchi. 

Large, moist, or coarse rales are heard in the 
large and middle bronchi, and result from the air 
passing through fluid. They are present in cases 
of bronchitis, both acute and chronic, and when 
there is fluid in the bronchial tubes, as in hemopty- 
sis, edema, etc. 

Small, fine, mucous, or subcrepitant rales are 



THE CLINICAL EXAMINATION. 



heard in the smaller tubes, the result of air passing 
through fluid, and are heard in cases of capillary 
bronchitis, broncho-pneumonia, pulmonary edema, 
congestion, chronic bronchitis, and during the last 
stages of phthisis. 

Sonorous rales are dry rales confined to the 
larger bronchi in which there is a narrowing of the 
calibre of the bronchi as the result of the deposi- 
tion of a layer of viscid mucus on their walls. 
They are not met with in cases of asthma, nor 
those conditions that lead to narrowing of the tubes. 

Sibilant rales are dry rales having the same 
causes as the sonorous, but are confined to the 
smaller tubes. Crepitant rales are confined to the 
ultimate air vesicles and are dependent upon the 
opening of the collapsed air vesicles; they are heard 
in the very early stages of croupous pneumonia, 
incipient tuberculosis, and in the lungs of weakened 
individuals. 

Friction sounds are heard in cases of inflamed 
and roughened pleura. They are grating, creaking, 
or rasping in character; and are usually most 
marked at the end of inspiration and the beginning 
of expiration. They are not removed, nor do they 
change their location, by coughing, as do rales, and 
they are not heard when the breath is held. 

Metallic tinkling is heard at times in cases of 
abscess and pneumo-hydrothorax when they com- 
municate at a higher level with a bronchus, from 
which there is a fluid dropping into the cavity. 

Post-tussive suction is heard in cases where there 
is a cavity with yielding walls, which are com- 
pressed during coughing but which produce a suc- 
tion sound upon re-expansion. 



20 THE CLINICAL EXAMINATION. 

Mensuration is employed in ascertaining the size 
of the patient and whether the sides are symmetrical 
or not. 

Succussion is the term used to designate a shak- 
ing of the body while the ear of the examiner is 
over the thorax to determine the presence of fluid. 
This is only of service where both air and fluid 
are present. 

Alteration of the position is practiced at times in 
cases of flatness over the pleural cavity, to ascer- 
tain if the flatness changes its position. 

Hypodermic exploration is of service in distin- 
guishing the character of fluids, also when it is 
difficult to distinguish between solids and fluids. 

" The spirometer is used in measuring the amount 
of exhaled air, but is of little service. 

The stethometer is an instrument for measuring 
and contrasting the movements of the two sides of 
the chest. 

The manometer is used in estimating the power 
exercised during normal and forced breathing. 



CHAPTER III. 
PATHOLOGY. 



The lungs are composed of three sets of chan- 
nels: bronchial tubes, blood vessels, and lymphatics; 
these are supported by a framework of connective 
tissue. An}^ structural change has its origin to a 
great extent in one of these elementary parts. 

In its etiology, pulmonary pathology divides 
itself into those conditions that render the system 
less resistant, or that are predisposing; and those 
that are specific or immediate in their action, which 
are also known as the determining. Under ordinary 
conditions the system is capable of resisting disease 
by its inherent vitality, and power of adjusting 
itself to its environments; but when a certain inten- 
sity is reached it is no longer able to resist, and 
disease or injury results. The degree of resistance 
varies in individuals, and in the different races to 
such an extent that certain diseases are almost 
unknown among certain peoples, to which condi- 
tion the term immunity is applied. In others there 
is a weakness of resistance to certain diseases. 
This constitutes a predisposition which may be 
acquired or inherited. The former follows as a 
result of previous disease, or unfavorable environ- 
ments. 

While heredity does not form so prominent a 
factor as it was once thought to, yet there is a 
weakness, or lack of resistance of the cells that 
predisposes to certain diseases. This hereditary 



2 2 PATHOLOGY. 



predisposition may be immediate, from the father, 
or mother, or more remote, being latent in the 
parents. Of the determining causes there are those 
that have their origin outside of the body, and 
those that originate within the body. 

Irritation is the most common cause of the vari- 
ous forms of inflamrnation to which the lungs are 
subject. This irritation, if long continued or often 
repeated, not only does permanent injury to the 
lung, but indirectly injures the heart, and deranges 
the nervous system. The source of this irritation 
matters but little; whether it is the result of heat 
or cold, mechanical or chemical agents, micro-organ- 
isms or their products, the results are nearly iden- 
tical. The changes wrought are the result of the 
direct irritation, combined with those produced by 
the attempt on a part of the S3^stem to throw off 
the irritation, as in coughing and dyspnea. 

The phenomenon of coughing is worthy of con- 
sideration from a pathological standpoint, as it is 
present in nearly all pulmonary diseases, and in 
many others in which it is reflex. During the early 
stages of bronchitis when the bronchial mucous 
membrane is highly inflamed and dry, the forcible 
coughing that is present is injurious, not alone to 
the highly inflamed membrane, but also through its 
tendency to cause a dilatation of the weakened 
part of the bronchial tube. Later, if not too vio- 
lent, when the secretions become more profuse, it 
is beneficial in removing the decomposed secretions. 
Still later, as the process becomes more chronic, it 
often becomes injurious in that the extra force 
dilates the atrophied bronchial walls, leading to 
bronchiectasis. During the first and second stage 



PATHOLOGY. 23 



of pneumonia there may be but little coughing, and 
this may not be of any special injury, while later, 
during the stage of resolution, the cough assists by 
clearing the bronchial tubes. Though most of the 
exudate is removed by the lymphatics, in cases of 
pleurisy and fibroid diseases of the lung, coughing 
is of little or no benefit and often does positive harm. 

In cases of phthisis the cough is frequently 
laryngeal in origin, is very distressing and accom- 
plishes nothing that is beneficial. But in those 
cases where there is material to be expectorated 
and the patient controls the cough until sufficient 
has accumulated, the cough is beneficial. It is in 
the cases of emphysema and bronchiectasis that the 
markedly injurious effects of coughing are observed; 
dilatation of the air cells in the former, and of 
the bronchial walls in the latter. 

Should the cough be severe and long continued, 
there are established certain definite changes in the 
lungs, heart and vascular system. These changes in 
the lungs are considered under their separate head- 
ings. In the heart the changes are in the form of 
a dilatation and hypertrophy of the right auricle 
and ventricle, and later the whole venous system is 
affected; as the result of this, venous congestion of 
the various organs takes place. These changes are 
usually seen first in the liver, and on account of 
its relation to the venous system, it becomes greatly 
congested, but later undergoes atrophy. Suffering 
from the same venous congestion the kidneys soon 
show structural changes, and albumen appears in 
the urine. All of the other organs also suffer from 
this general interference with the circulation, the 
connective tissue becomes water-logged, and anasarca 
with all its unpleasant accompaniments is developed. 



24 PATHOLOGY. 



Dyspnea is a difficult breathing that is observed 
in various pulmonary diseases, and is dependent 
upon different causes. It is present when there is 
a deficiency of oxygen, or an excess of carbonic 
acid gas in the respired air; in those cases in which 
for any reason the air is not permitted to pass to 
the lungs with sufficient rapidity, and in sufficient 
quantities to the air cells; or where the air cells 
have been rendered incompetent to the extent that 
they are unable to meet the demands of the system. 
The cause may be a circulatory one in which the 
blood is not allowed to pass readily through the 
lung. It may be dependent also upon an undue 
stimulus conveyed to the medulla by the vagi, or 
upon irritation of the respiratory center in the bulb. 

Dyspnea is not so frequent an accompaniment 
of lung disease as it is of heart disease. This is 
dependent to an extent upon the fact that during 
ordinary respiration the full capacity of the lungs 
is not employed. In cases of pneumonia and pul- 
monary tuberculosis it is seldom complained of 
except upon exertion or where there is a marked 
cough. It is observed in cases of asthma, emphy- 
sema, pneumothorax, and acute tuberculosis; it is 
frequently present through the greater part of a 
case of acute bronchitis, and is especially marked 
during capillary bronchitis. In cases of pulmonary 
embolism, thrombosis, collapse of the lung, and 
pneumothorax, the suddenness of the onset often 
gives rise to marked d3^spnea; for in these cases it 
is the lack of ox37gen more than the excess of car- 
bonic acid that produces the dyspnea. 

When the blood is imperfectly oxygenated, the 
respirations become increased in number and depth. 



PATHOLOGY. 25 



If for any reason the oxygen is not supplied in suf- 
ficient quantities, the vaso-motor centers are at once 
excited, leading to a contraction of the arterioles 
which results in the filling of the veins. This is 
only partially relieved by the forced action of all 
accessory muscles of respiration. The heart fills 
readily, but owing to the high arterial tension the 
diastolic intervals are lengthened and the myocar- 
dium weakened. The heart passes on to dilatation 
and finally ceases, the arteries are empty, the veins 
engorged, and the heart cavities filled with blood. 

When there is but a small portion of the lung 
incapacitated the blood is aerated by an increase in 
the rate of breathing. This increase of the respira- 
tions assists by increasing the velocity of the pul- 
monary circulation, thus bringing a greater volume 
of blood in contact with the air. This fine adjust- 
ment between the respiration and pulmonary circu- 
lation may be disturbed, resulting in an exhaustion 
of the natural reserve and increased dyspnea. 

As the d3^spnea becomes more pronounced 
cyanosis or carbonization of the blood is noticed, in 
which there is an excess of carbonic acid and a 
deficiency of oxygen. This may be dependent upon 
either a deficiency in the quantit}^ of air exposed to 
the blood in the lungs, or to a defect in the expos- 
ure of the blood to the air; in other words it 
depends upon some defect in either the respiratory 
or vascular system. Like dyspnea, it may be 
approaching for some time before it is noticed, as 
there is a reserve force to be exhausted first. Its 
appearance may be stayed for a time, by limiting 
the muscular exercise, and strengthening the right 
ventricle. 



26 PATHOLOGY. 



Cyanosis may be an early symptom of certain 
forms of heart disease, especially mitral stenosis; 
though in pulmonary disease it is usually a late 
symptom. In some cases, as in advanced chronic 
phthisis the anemia is so marked that the cyanosis 
cannot be noticed. It finds its fullest development 
in full blooded plethoric individuals. The skin and 
mucous membrane are of a dull, leaden, or bluish 
color, the temperature of the body is lowered, and 
the skin is cold and clammy. The functions of the 
body become markedly imperfect and the patient 
lapses into unconsciousness. While not definitely 
proven there is reason to believe that the poisonous 
alkaloids circulating in the blood may give rise to 
many of these symptoms. 



I 



CHAPTER IV. 
THERAPEUTICS, 



The clinical history of the patient must be con- 
sidered, for while not so much importance is given 
to heredity as formerly, there is an intrinsic physi- 
ological or anatomical abnormality in connection 
with certain diseases which may be traced from 
generation to generation ; and these by early care 
and training may be counteracted to a great extent. 
While heredit}^ has an important influence it must 
be considered secondary to environment, in the role 
of etiological factors, as well as in treatment. 

The home life should be considered, for while it 
cannot in itself develop a disease requiring a spe- 
cific germ, yet the constant suggestion that one is 
ill will certainly lead to an impoverished physical 
condition, by restricting the appetite and outdoor 
life, and thus rendering the individual a fit subject 
for the invasion of nearly any disease. The home 
life should be one of cheerfulness, rather than of 
discouragement. The sleeping rooms of every one 
possessing a tendency to pulmonary disease should 
be clean, well lighted and thoroughly ventilated, 
especially during the hours of sleep. Neither the 
room nor bed should be damp, and while the bed 
clothing should be sufficient at all times it should 
not cause sweating, and thus debilitate the patient. 
The head should not be raised too high by pillows. 

The climate is a vital subject in the manage- 



THERAPEUTICS. 



ment of all cases, but it must be studied in the 
light of the individual. 

The system in sreneral should be considered: an 



impoverished condition always favors the develop- 
ment of a formidable disease. 

In remedying this condition attention must be 
devoted tirst to the hygiene and dietetics, rather 
than to the remedies upon which we too often rely 
to a great extent. 

The condition of every organ of the body 
should be ascertained before undertaking the treat- 
ment. Each in turn may be responsible, or assist 
in continuing the pulmonary affection; especially is 
this true of the nares, pharynx, heart and kidneys. 
The skin should be kept in a healthy state. 

The majority of people drink too little water in 
pulmonary diseases. Unless contra-indicated, as in 
pleurisy with effusion, a large quantity of water 
should be taken each day. 

Much attention should be devoted to the diet. 
It must be moditied to meet the individual case; 
many of these patients are anemic and need foods 
that are rich in carbohydrates and albuminoids. 

The clothing should be sufficient at all times. 

The type of a patient's breathing is frequently an 
index of his vitality. Correct breathing not only 
ventilates the lungs, but by changing the position 
of the abdominal organs, assists their blood supply, 
exercises the muscles of these organs, relieves a 
tendency to congestion and gives a sense of com- 
fort and relief. It should always be performed 
throucrh the nose as it thus ventilates the chambers 
of the head, as well as purifies and warms the air 
before it reaches the delicate structures of the lar- 



THERAPEUTICS. 29 

ynx and more remote parts of the respiratory tract. 
The body should be erect and slightly bent forward 
at the hips, the shoulders back, and the head up. - 
To those not accustomed to this carriage of the 
bod}^ it will be uncomfortable at first, but it will 
soon become the habitual position, giving a sense 
of well being in a short time. It should not be 
carried to excess at first so that the lungs are 
made sore and the head giddy, but it should be 
made a habit at regular intervals. That this may 
be carried out to the best advantage the nares and 
pharynx should be in a normal condition, in fact, 
they should be inspected in every case of pulmo- 
nary disease. 

Not only should one breathe properly, but time 
should be devoted each day to respiratory exercises 
which have for their object not only the restoring 
of portions of the lungs that are inoperative, but 
the prevention of - any further advancement of the 
disease; the regulating of the respired air having 
an influence over the flow of blood and lymph, 
keeps the thorax more mobile, and the lung elastic, 
thus increasing the pulmonary capacity. A distinc- 
tion should be made between pulmonary exercise 
intended to develop the lungs, and gymnastics that 
develop the muscles of the thorax only, and in no 
way assist the thoracic capacity. These exercises 
should be persisted in whenever there is any lung 
disease that results from pulmonary collapse. 

The first requisite to proper breathing is that 
there be no resistance to the movements of the 
thorax. This is usually met with either in the 
form of tight clothing or obesity. The deep 
breathing should be practiced in an atmosphere that 



30 THERAPEUTICS. 



is free from impurities, that they may not be 
inhaled. 

During the exercise many of these cases will 
require an extra diet that the nutrition may be 
improved. The muscular S37stem, and especially 
the accessory muscles of respiration, should be 
strengthened by general exercise and the use of 
dumb-bells; these should not weigh more than two 
or three pounds. The diaphragm will need exer- 
cise to strengthen it; this may be accomplished by 
placing a weight upon the abdomen when the 
body is in a horizontal position, and contracting the 
diaphragm against it. 

The patient should be taught how to produce 
the different types of breathing; as the abdominal 
and costal types produce different physiological 
effects. 

Diaphragmatic breathing is best learned in the 
recumbent position. All restrictions having been 
removed, the abdomen is made to protrude to the 
greatest possible extent with each inspiration, while 
the thorax is fixed. Following this the diaphragm 
returns to its position as the result of the thoracic 
recoil, and the pressure from the abdominal organs. 

The costal type of breathing should be practiced 
both in the horizontal and upright positions, the 
ribs being raised each time to their utmost, while 
the abdominal wall is kept stationary. This having 
been accomplished, the patient should next be taught 
to expand the upper and lower parts of the thorax 
independently. There is usually but little difficulty 
in expanding the apices of the lung; but more diffi- 
culty will be experienced in developing one lung 
more than the other. 



THERAPEUTICS. 3 1 



Should there be a tendency to hemoptysis, the 
exercise should always be taken cautiously. The 
following exercises will be found of service : 

1. Take a deep upper thoracic inspiration fol- 
lowed by a deep upper thoracic expiration. 

2. Take a deep lower thoracic inspiration fol- 
lowed by a deep lower thoracic expiration. 

3. Standing with the legs well apart take a deep 
abdominal inspiration, then a lower thoracic inspira- 
tion, lifting the clavicle at the same time; this is to 
be followed by an expiration in the reverse order 
slowly and fully. 

4. Have the patient stand erect, the shoulders 
back and down, and while in this position take a 
full inspiration, hold the breath for a short time, 
and expire fully. After this has been prac- 
ticed for a time forced expiration should be in- 
troduced by causing the patient to bend forward 
during expiration. 

5. When but one lung is to be expanded have 
the patient place his hand upon the opposite side in 
such a position that it will restrict the movements 
of that side, and while pressing firmly during in- 
spiration, the upper portion of the body is swayed 
to that side while the arm upon the side that is 
being expanded is raised from the side, thus assist- 
ing in its expansion. Or the opposite side may be 
restricted by pressing it against the back or sides 
of a chair, the arm of that side being carried over 
the back and the hand grasping one of the rounds, 
and while pressing firmly against the chair take a 
full, deep inspiration. 

6. Bending forward, clasp the hands behind the 
neck, and with the mouth closed inspire slowly, 



32 THERAPEUTICS. 



steadily, aud fully, while assuming the erect posture; 
after a short period expire slowly, while flexing the 
body forward, expelling all the air possible. 

7. In the erect position take a slow, deep inspi- 
ration through the nose; while the breath is being 
held in the lung have the patient count, the object 
being to see how many can be counted while the 
breath is being held. Repeat this several times at 
each exercise and have stated times each day for 
the exercise; increase the length of time the breath 
is held. 

8. To develop the diaphragm the patient should, 
while in a recumbent position, take a deep abdomi- 
nal respiration; after a few trials the abdomen 
should be gradually weighted, and the weight and 
abdominal walls raised by the contractions of the 
diaphragm. 

9. With the patient upon a narrow couch in 
the supine position, stand at his head, grasp his 
arms and bring them around above the head; 
he is meanwhile to take a full, deep inspiration; 
traction should be made upon the arms while they 
are above the head. The arms are then brought 
back to the thorax and firm pressure is made upon 
it while the patient makes a deep expiration. 



CHAPTER V. 
DISEASES OF THE TRACHEA. 



ACUTE TRACHEITIS. 

Definition: — This is an acute catarrhal inflam- 
mation of the trachea. 

Etiology: — The most frequent cause is an ex- 
tension of an acute pharyngitis or laryngitis down- 
ward to the trachea and bronchi. Occasionally the 
process starts in the bronchi and extends upward, 
or it may be primarily in the trachea. 

Pathology : — This is similar to that met with 
in acute bronchitis; the mucous membrane is so red 
and swollen that the ring-s of the trachea cannot be 



■to 
seen. 



Symptoms: — The most constant symptom is a 
feeling of rawness or soreness along the trachea and 
behind the upper part of the sternum, accompanied 
by a dry harsh cough. This in time becomes 
moist, is accompanied by an expectoration of mucus, 
and later muco-purulent material; occasionally there 
are traces of blood. Should the larynx be in- 
volved, hoarseness will be present. The pulse is 
quickened, and in some cases fever is present, but 
this is not constant. Examination with the laryn- 
goscope shows inflammation of the tracheal mucous 
membrane. 

Diagnosis: — This is based upon the symptoms 
as given. 

Prognosis : — The prognosis is favorable so far as 
recovery is concerned, but a chronic condition is 
liable to develop. 



34 DISEASES OF THE TRACHEA. 

Treatment : — If possible, the patient should re- 
main in a room of about the same temperature 
night and da}^; 65° to 70° F and all draughts care- 
fully avoided. If the case is a severe one a moist 
atmosphere will prove grateful; additional benefit 
will be derived by adding to boiling water some 
such preparation as the compound tincture of ben- 
zoin. In those cases where there is a great amount 
of pain, local applications to the trachea will relieve 
the patient. Apart from steam inhalation, oil spra3's 
of thymol or eucalyptol (5 per cent.) in fiuid vase- 
line are beneficial. The diet of the patient should 
be light. If fever is present a sponge bath of warm 
water containing bi-carbonate of soda, followed by 
thorough friction is beneficial. Any tendency 
toward constipation should be corrected at once. 

Aconitum: — When the, physician is called early 
in the case, and if the disease is the result of 
exposure to wet, or cold dry winds this is usually 
the remedy. In the trachea there is a sensation of 
burning, or dryness, which causes a frequent cough. 

Sanguinaria: — Usually, after a few doses of 
aconite, this is the next remedy indicated; when it 
controls the extension of the disease to the bron- 
chial tubes, and removes the tendency to recurrent 
attacks. There is a dr}^ hacking cough which at 
times is violent, and is caused by a dryness of the 
throat; it is accompanied by a crawling sensation 
that extends down behind the sternum and is worse 
at night. 

Tartarus erneticus: — When there is a great quan- 
tity of mucus present, with an audible rattling in 
the trachea and bronchi. The sputum is tough, 
white, copious, and produces a tendency to vomit 
during its expulsion. 



DISEASES OF THE TRACHEA. 35 

Mercurius solubilis: — When the tracheitis is but 
a part of a general catarrhal condition, the patient 
is sensitive to cold; chills alternating with burning 
heat; there is also present a dry, distressing, hack- 
ing cough, worse at night, and which racks the 
whole frame. 

Spongia tosta: — This remedy is to be thought 
of when the cough is hoarse, ringing, hollow, 
paroxysmal, and without expectoration. The res- 
pirations are labored and of a wheezing character. 

Hepar sulphur: — Frequently this remedy is 
needed to close the treatment when there is a dry 
cough with a feeling of constriction in the chest, 
which is worse after eating, and during deep inspi- 
ration. 

CHRONIC TRACHEITIS. 

Etiology: — The causes are the same as those 
giving rise to chronic laryngitis or bronchitis. It 
may be a sequela of the acute form. 

Pathology : — The mucous membrane is of a 
dark pink color, dotted with irregularly swollen 
points; masses of mucus may be seen over the 
mucous membrane; rarely are ulcers observed, but 
at times dessicated and decayed secretions are 
seen covering the surface. 

Symptoms: — There is usually a sense of dis- 
comfort, though it seldom amounts to actual pain. 
Frequently there is a tickling that may be asso- 
ciated with a continuous coughing, or hemming to 
clear the throat; at times the cough may be par- 
oxysmal in character. The expectoration may con- 
sist of a small amount of thick mucus. In some 



36 DISEASES OF THE TRACHEA. 

cases there is a slight hoarseness or loss of voice 
upon attempting to sing. 

Diagnosis: — This is based upon the history of 
the case and laryngoscopic examination. 

Prognosis : — While not serious, many of these 
cases are very obstinate. 

Treatment : — This is much the same as that for 
chronic laryngitis and bronchitis. The patient will 
be benefited by a prolonged residence in an equa- 
ble climate, and should avoid exposure at all times. 
Any constitutional disease that may be present 
should receive treatment. It is difficult to utilize 
a spray here as the closure of the glottis takes 
place as soon as it is brought into use, unless the 
patient is taught to cough while it is being used; 
oil sprays of eucalyptol, thymol, and benzoinol are 
preferable. A powder may be used with good 
results, applying it by means of a bent glass tube 
and an ordinary insufflator, while the glottis is 
open. A powder consisting of equal parts of 
iodol and boric acid is of service. 

The remedies are much the same as are indi- 
cated in chronic bronchitis. 

DIPHTHERIA. 

During this disease, when the larynx is involved, 
the exudation may extend down to the trachea, 
and along the main bronchi to the smaller bron- 
chial tubes. The membrane is lightly attached to 
the trachea in the form of a cast while in the 
small tubes it is more puriform. 

The symptoms of diphtheria involving the trachea 
differ from those of the larynx in degree, being 
more severe as the process advances; the dyspnea 



DISEASES OF THE TRACHEA. 37 

is more pronounced, cyanosis appears, and there 
is greater retraction of the lower ribs during in- 
spiration. 

The treatment of these cases, while along the 
same line as those where the larynx is involved, 
demands tracheotomy, as the intubation tube does 
not reach low enough to be of service. 

TUBERCULOSIS OF THE TRACHEA, 

Tuberculosis of the trachea is usually second- 
ary to involvement of the lungs; the anterior sur- 
face is the part most frequently involved, show- 
ing round superficial erosions, and ulcers, which in 
time unite and leave the cartilage exposed. 

The symptoms of tuberculosis of the trachea 
are often overshadowed by those of the lung and 
larynx; yet in some cases there may be much 
pain in the trachea which becomes excruciating 
upon coughing. 

The treatment is that of general tuberculosis, 
together with the management of the involvement 
of the trachea, which is often very painful. 

Syphilis: — The trachea suffers from the second- 
ary effects of syphilis, and demands the treatment 
incident to that disease. 

NEW GROWTHS OF THE TRACHEA. 

While new growths are not common in the 
trachea, they do occur. Papilloma, polypi, cartila- 
ginous and osseous growths are occasionally pres- 
ent. The symptoms are those of a gradually de- 
veloping obstruction. Both the diagnosis and 
treatment may demand tracheotomy. 



38 DISEASES OF THE TRACHEA. 

STENOSIS OF THE TRACHEA. 

Definition: — This is a narrowing of the trachea. 

Etiology: — It may arise as a result of syphilis 
when there is a gummatous infiltration of the 
mucosa, which being absorbed, leaves a cicatrix; 
or in other cases it may ulcerate, when contrac- 
tion follows, producing the same results. The 
irritation due to the presence of a tracheotomy 
tube has been known to produce granulation tissue 
which, becoming organized, contracts. Pressure 
from without produces stenosis; this may be the 
result of enlargement of one or both lobes of 
the thyroid gland, or an enlargement of its isth- 
mus may lead to its compression anteriorly. En- 
larged cervical and bronchial glands, the result of 
tuberculosis or syphilis, cause stenosis as well as 
aneurism and abscesses. At times it results from 
the extension of disease from the surrounding 
organs. 

Symptoms : — The growth is usually easily rec- 
ognized, and accounts for the dyspnea and cyanosis. 
In those cases where the cause is within the thorax, 
a careful physical examination must be resorted to. 
In cases of aneurysm of the transverse portion of 
the arch of the aorta, tracheal tugging may be 
recognized. Marked stenosis of recent date should 
always lead one to think of the development of a 
new growth. When the symptoms develop slowly 
syphilis should be thought of. 

Prognosis : — This depends upon the cause, and 
whether it be amenable to treatment. 

Treatment : — This varies according to the cause; 
when the result of aneurysm of the arch of the aorta, 



DISEASES OF THE TRACHEA. 39 

absolute rest in bed and the employment of such 
remedies as will meet the condition should be em- 
ployed. Of the remedies of service, possibly none 
are of more value than the iodide of potassium or 
sodium, in increasing doses, commencing with ten 
to fifteen grains three times a day. Frequently, 
before the remedy has had time to act, inhalation 
of oxygen will be found to give relief during the 
paroxysms of dyspnea. Tracheotomy v/ill have 
to be resorted to in many cases; but before resort- 
ing to it the seat of the stenosis should be ascer- 
tained in order that the opening may be made 
below it. In cases due to syphilis, tracheotomy 
may not give much relief, as the pathological pro- 
cess extends so low that it is impossible to get 
below it. 

PERFORATION OF THE TRACHEA. 

Aneurysms, caseolis lymphatic glands, or 
growths originating outside of the trachea may 
perforate it, and are easily recognized. 

Foreign bodies may find lodgment in the 
trachea but more frequently they are found in one 
of the bronchi. These can often be located by the 
Roentgen rays, or tracheoscopic examination. The 
treatment consists in their removal by long tracheal 
forceps, also by tracheotomy. 



CHAPTER VI. 

ACUTE BRONCHITIS OF THE LARGER 
TUBES. 



Synonyms: — Bronchial catarrh; cold in the 
chest. 

Defijiition: — This is an acute catarrhal inflam- 
mation of the bronchial mucous membrane. 

Etiology: — It is due to a sudden change of 
the temperature, especially when combined with 
high winds and dampness; exposure of a portion 
of the body, as from draughts on the back, sit- 
ting on damp ground, getting the feet wet, going 
from a hot, ill-ventilated house into cold, damp 
air; or prolonged inhalation of over-heated, noxious 
air; living amid unhygienic surroundings; work- 
ing in a dusty atmosphere and inhaling pun- 
gent gases. It is secondary to certain acute or 
chronic diseases, such as measles, typhoid or 
scarlet fever, smallpox, gout, rheumatism, diabetes, 
syphilis and influenza. 

Teething children, those suffering from nasal 
catarrh, hypertrophied tonsils, adenoid growth, and 
mouth breathing, as well as in those where there 
is a lack of resistance, cardiac disease, Bright's 
disease, tuberculosis, cancer, regular and habitual 
drinking, the use of tobacco, self-indulgent habits, 
lack of out door exercise, and other causes that 
promote digestive disturbance, predispose to acute 
bronchitis. 

An acquired susceptibility, the atmospheric in- 



ACUTE BRONCHITIS OF THE LARGER TUBES. 4I 

fiuences, as well as asthma, gout, .and rheumatism 
are predisposing causes. There is a gradual 
increase in its frequency from mid-summer to mid- 
winter. 

Pathology : — In ordinary uncomplicated cases 
the inflammation is limited to the trachea, the large 
and middle si^ed tubes, and has but little effect 
on the function of the lungs. The mucous mem- 
brane is intensely red and dry at first, but later a 
mucous, or muco-purulent exudate is formed on 
it. The process begins with an engorgement of 
the vessels of the inner connective tissue layer, 
which causes the redness and swelling. It is infil- 
trated with round cells, this being most marked in 
the purulent cases. The epithelial cells are degen- 
erated, while the mucous glands are distended with 
mucus. The inflammatory process may extend 
outward as far as the peri-bronchial tissue, and a 
peri-bronchitis results. The bronchial glands may 
be involved, leading to recurrent attacks. As the 
inflammation ceases there is a gradual return to 
the normal, and healing takes place. The process 
may become purulent or even gangrenous, and 
extending downward may interfere with the lumen 
of the bronchial tube, and atelectasis result. 

Symf>to7ns : — The patient complains of a general 
malaise, thirst, pain in the limbs and about the 
chest, especially under the sternum; these are in 
proportion to the severity of the attack. The 
tongue is furred, the pulse quickened, the face 
flushed, there is some headache, and the bowels 
are usually sluggish. Cough is an early symptom 
varying in intensity. It may be paroxysmal in 



42 ACUTE BRONCHITIS OF THE LARGER TUBES. 

character, attended with incontinence of urine, and 
is worse at night, producing insomnia. At first 
it is dry although later it is attended with a mucoid 
or muco-purulent expectoration; while in cachetic 
and alcoholic individuals it may be tinged with 
blood. A feeling of dryness is complained of 
which is located in the upper sternal region, ac- 
companied at times with hoarseness, wheezing and 
dyspnea, but with little impairment in the respira- 
tory function. There is usually a slight rise in 
the temperature — ioo° to 102° F. The appetite is 
impaired or lost. A mild attack will last from 
one to two weeks; but should there be any ex- 
posure the attacks will be renewed, the process 
extending farther into the tubes, and its duration 
lengthened. 

Physical Signs: — Inspection. This may be 
negative, but in some cases the respirations are 
accelerated, and dyspnea is occasionally seen in 
infants, the aged, and the enfeebled. 

Palpation: — This will not give any more infor- 
mation at times than inspection. In some cases 
the pulse is quickened, the surface temperature 
elevated; and where there is much secretion in the 
bronchial tubes bronchial fremitus is present, 

Percussion: — With the exception of occasionally 
a slight dullness over the lower part of the chest, 
which cannot be demonstrated after free expecto- 
ration, this gives little or no information. 

Auscultation: — The vocal resonance is normal; 
the respiratory sounds are often harsh over the 
larger tubes, while the vesicular murmur is dimin- 
ished if the mucus is sufficient to partially or 
wholly close a bronchial tube. Rales, that are at 




Sibilant rales 

Subcrepitant rales 

Sonorous rales 
Mucous rales 



Large 

sonorous 

rales 



i# 



PHYSICAL SIGNS OF BRONCHITIS. (FROM LOOMIS) 



44 ACUTE BRONCHITIS OF THE LARGER TUBES. 

first dry and later become moist, are heard bilater- 
ally. They vary in intensity and location, and 
usually disappear upon coughing, from a deep in- 
spiration, and from expiration. 

Co7nj)lications and Sequel ce: — The most common 
are capillary bronchitis, broncho-pneumonia, em- 
physema, circulatory disturbances and phthisis. 

Diagnosis: — This is based upon the history of 
the case, the sub-sternal distress, with a dry cough 
followed by a muco- or muco-purulent expectora- 
tion later, together with the physical signs. 

Acute bronchitis should be differentiated from 
acute miliary tuberculosis. 

ACUTE BRONCHITIS. ACUTE MILIARY TUBERCU- 

LOSIS. 

1. Slight elevation of the tern- i- Temperature is higher with 
perature, and is nearly con- oscillations. 

tinuous. 

2. Slight dyspnea. 2. Dyspnea more marked. 

3. Respirations increased. 3. Respiration still more rapid. 

4. No pulmonary consolida- 4. There is pulmonary consol- 
tion, or softening. idation and softening. 

5. Constitutional symptoms 5. More pronounced emacia- 
are mild. tion, hectic fever, and grad- 
ual failing of the vital forces. 

6. Usually recover. 6. Usually die. 

7. No tubercle bacilli present 7. Tubercle bacilli are present, 
in sputum. 

Prognosis : — This is favorable in otherwise 
healthy individuals. In the aged, the tubercular, 
the gouty and debilitated, there is always a ten- 
dency for the disease to extend downward and in- 
volve the smaller tubes, giving rise to capillary 
bronchitis, bronchiectasis, broncho-pneumonia and 
atelectasis. 



ACUTE BRONCHITIS OF THE LARGER TUBES. 45 

Treatment : — The age of the patient, the period 
of the disease, and its nature, whether primary 
or secondary, should always be taken into con- 
sideration. If secondary, the underlying disease 
should receive attention. In some cases there is 
but little demanded; a copious perspiration is 
beneficial in the first stage. This is usually ac- 
complished by a hot foot bath, a hot lemonade 
upon retiring and plenty of bed clothing, that no 
chilling may result; and a thorough friction rub 
the next morning is often sufficient. A Turkish 
bath is not desirable if the patient is obliged to 
go into the cold air to reach home. If possible 
the patient should not go out during the attack, 
and should remain in bed if fever is present. If 
there is much distress in the chest the air of the 
room should be moistened and kept at a tempera- 
ture of about 70° to 75° F. The room should be 
well ventilated. In some cases a wet compress 
upon the chest, or a mustard plaster prepared in 
boiling castor oil, and left on the chest twelve to 
fourteen hours is serviceable. In young children 
a full hot bath is often of service. Some prefer 
a wet pack with the water 68° to 75° and renewed 
two or three times a day; a simple cotton jacket, 
or a flaxseed poultice. The bowels should be 
thoroughly evacuated once a day; an enema of 
water or glycerine will accomplish this if there is 
constipation. 

The diet should be light but nourishing, and 
hot drinks may be given in abundance. Should 
the expectoration be profuse there must be a 
nourishing diet of albuminous food, milk gruels. 



46 ACUTE BRONCHITIS OF THE LARGER TUBES. 

and in the aged alcoholic stimulants may be 
needed with the food. 

These patients should devote much attention to 
their clothing that it be sufficient at all times. 
They should avoid drafts, and should keep the 
skin in a healthy condition, by taking cold sponge 
baths on the chest and neck, followed by thorough 
friction, and such breathing exercises as will de- 
velop the weak lungs. 

Belladonna: — At the beginning of an attack when 
the fever is high, the cough is dry, distressing, 
and either continuous or spasmodic. The respira- 
tions are rapid and irregular; there is no expec- 
toration, or, if any, it is but small in amount, 
tenacious, and blood streaked. A sense of fullness 
is complained of in the chest, which hardly amounts 
to a pain, although at times the child may cry as 
a result of coughing. The skin is hot and moist. 
The patient is drowsy but does not sleep, he ap- 
pears to be passing into sleep, starts, and thus does 
not get the rest needed. 

Aconitum: — At the beginning of the attack, 
before the inflammatory process is established, 
when there has been an exposure to dry, cold 
winds. Fever is present; the skin is dry and hot; 
the pulse is full, hard and strong; the cough is 
dry and hacking, and the patient is restless and 
tosses about. This is frequently the remedy for 
children and robust adults. 

Mercurius: — As the inflammatory process be- 
comes established. The period of the usefulness 
of aconite is passed. There is a tendency to per- 
spire but it brings no relief. The tongue has a 
thick yellow coating. There is a feeling of dry- 



ACUTE BRONCHITIS OF THE LARGER TUBES. 47 

ness, roughness, and soreness from the fauces 
down the middle of the chest. The cough is vio- 
lent and exhausting, and is worse from evening to 
midnight. Each paroxysm of coughing is preceded 
by dyspnea. The expectoration is tenacious, yel- 
low, and sometimes tinged with blood. 

Bryonia: — This is one of the abused remedies; 
it is often given in bronchitis when not indicated. 
It is seldom indicated at the commencement of 
an attack, but is later, when the cough is violent, 
spasmodic, and excited by a titillation low down 
in the chest. The cough causes so much distress 
in the head and chest that the patient places his 
hand to the chest or head to support it during 
the paroxysm. Frequently there is an escape of 
urine at this time. The expectoration is scanty, 
yellowish, and tinged with blood. The cough is 
attended with turgescence of blood to the head 
and face. There are violent stitching pains. 

Ferrum phosphoricum: — This remedy is at times 
indicated in the first stage of those cases that do 
not appear with the severity of the typical aconite 
cases. The pulse is full but soft. There is heat 
with burning, soreness in the chest, and but little 
expectoration, which is generally blood streaked. 
Many of these patients are anemic and show other 
symptoms calling for this remedy. 

Nux vomica: — For those patients that have been 
taking the various cough mixtures. The patient is 
irritable and over-sensitive to light, noises, and 
smells. The nose is stopped up in the evening, 
there is headache and fever accompanied with chil- 
liness from the slightest motion. The cough is 
dry and fatiguing, from titillation in the larynx. 



48 ACUTE BRONCHITIS OF THE LARGER TUBES. 

and is worse after midnight; there is hoarseness, 
with roughness, rawness and scraping in the chest; 
there is pain in the stomach, and soreness in the 
abdominal walls. 

Gelsemium: — In cases of bronchitis occurring 
during warm, damp, relaxing weather, and when the 
patient is dull, drowsy and prostrated. The pulse 
is slow and the arterial tension low. There is raw- 
ness and soreness in the chest, with tickling in the 
fauces. It is most frequently indicated in children, 
young people, and women of a nervous hysterical 
temperament who desire to be quiet; to be left 
alone; do not want to speak, or have any one near 
them. 

Phosphorus: — This remedy should be thought 
of in cases of young people who grow too rapidly, 
and who are tall, slender, and inclined to stoop; 
who are chlorotic and anemic, with quick percep- 
tion and very sensitive natures. There is tightness 
and oppression, with burning and rawness of the 
chest; the larynx being sensitive and dry. There 
is a tendency of the bronchitis to advance and 
involve the lung tissue. The cough is made worse 
by going from a warm room into a cold one, 
from laughing, talking, eating, and from lying on 
the left side. 

Pulsatilla: — This remedy should be used when 
there is a tendency of the process to become 
chronic. In individuals who are indecisive, with 
light hair and blue eyes, pale face, and who are 
easily moved to tears. The expectoration is thick, 
copious and easily raised, cough being loose dur- 
ing the day, but tight and dry at night. The 
patient complains of soreness in the epigastric 



ACUTE BRONCHITIS OF THE LARGER TUBES. 49 

region, is worse in a warm, close room, from 
warm applications, and from rich, fat food, and is 
relieved by being in the open air, and from cold 
food and drinks. 

Hepar sulphur: — The patient is of the torpid 
lymphatic constitution with a light complexion, is 
slow to act, and is extremely sensitive to cold, 
taking cold from the slightest exposure. The 
cough is dry and spasmodic, with wheezing in the 
whole chest, and is made worse by an attempt to 
draw a long breath or uncovering any portion of 
the body. It may be of service when the cough 
is loose, and there is hoarseness, with rattling in 
the chest as though the patient would choke. 

Arsenicum album: — This remedy is of service 
in cases that have either been allowed to go un- 
checked, or that complicate other diseases. There 
is great prostration, with sinking of the vital 
forces, attended with anguish, restlessness, and fear 
of death. The patient is worse immediately after 
mid-day and midnight, also from cold food and 
drinks, and is better from heat; there is a ten- 
dency to edema of the lungs, 

Hyoscyamus: — The cough is dry and constant 
while lying down but ceases when sitting up. At 
times there are violent paroxysms of spasmodic 
exhausting cough. 

Rumex crispus: — This is the remedy for tracheo- 
bronchial catarrh, when there is a violent, inces- 
sant, fatiguing cough, with but little expectoration. 
The cough is due to a tickling in the supra-sternal 
fossa. It is made worse by pressure at this point, 
by talking, and by inspiring cold air; this causes 
him to cover his head to exclude the cold air. 



50 ACUTE BRONCHITIS OF THE LARGER TUBES. 

Scilla: — There is irritation of the throat with 
heat, and tickling which causes coughing. The 
cough is loose in the morning, but dry and fatiguing 
at night, disturbing the sleep. There is headache, 
and dyspnea with spurting of the urine when 
coughing. There are sharp stitching pains in the 
chest and abdomen, and every fit of coughing 
ends with a sneeze. 

Codeinum: — This drug will be demanded at 
times when the cough is dry, fatiguing, and where 
it causes much pain and loss of sleep. 

Eriodictyon californicum ( yerba santa): — This 
remedy should be studied when there is slight 
fever, the cheeks are flushed and burning, with 
dull frontal headache and pharyngeal catarrh that 
causes a constant hawking constriction of the larynx; 
constant pressure under the sternum as if from a 
heavy weight, necessitating a deep breath at times. 
There is a sharp pain in the right lung. The 
cough is irritating and attended with an expecto- 
ration of glairy mucus. 

Antimonium iodatum: — When the whole chest 
is raw, there are frequent spells of coughing with 
expectoration of white, frothy or yellow material. 
The tongue is coated, there is loss of appetite 
with nausea and disgust of food. 

Grindelia robu'sta: — This remedy should be 
remembered in cases where the cough is at first 
dry and wheezing, without expectoration and when 
the bronchitis is always complicated later with 
asthma. The patient fears going to sleep on 
account of loss of breath, which awakens him. 



CHAPTER VII. 

ACUTE BRONCHITIS OF THE SMALLER 

TUBES. 



Synonyms : — Capillary bronchitis; suffocative 
catarrh; bronchitis. 

Definition: — This is an acute catarrhal inflam- 
mation of the smaller bronchial tubes. 

Etiology: — The causes of this form of bronchitis 
are similar to those that produce acute bronchitis 
in the larger tubes, combined with a more defec- 
tive resistance on the part of the patient. It is 
more frequently met with in those at the extremes 
of life, and is then generally secondar}^ to bronchitis 
of the larger tubes. When met with during middle 
life it is most frequently observed in those of the 
obese type who have been subject to repeated 
attacks of bronchitis, and especially in women of 
this type who lead a sedentary life and have a 
small chest capacity. It will be observed frequent- 
ly among those who are addicted to the use of 
alcohol. 

Pathology : — The changes are similar to those 
present in cases where the larger tubes are in- 
volved. The lungs may be distended with air; an 
emph3^sema may be present and in some cases 
areas of collapse may involve a whole lobe. Upon 
section, the lining membrane of the smaller bronchi 
is seen to be injected; a small particle of pus may 
be squeezed from some of them, whille others are 
completely blocked by secretions. Frequently the 



52 ACUTE BRONCHITIS OF THE SMALLER TUBES. 

alveoli share in the inflammatory process, and a 
broncho-pneumonia results. 

Symptoms: — The first indication of the disease 
may develop in the smaller tubes, or there ma}^ be 
an inflammatory process in the larger tubes, that 
has extended downward. The symptoms often 
appear suddenly. In the adult they may be ushered 
in by a chill or chilliness; in a child b}^ a convul- 
sion. The cough is paroxysmal, frequent, and 
accompanied by a pain in the chest; usually there 
is a little viscid adhesive expectoration which is 
expelled with diflSculty. The alse nasi are widely 
dilated, and expiratory dyspnea is extreme, often 
amounting to orthopnea early in the case. The 
respirations may be 60 to 80 to the minute. There 
is marked prostration, the face is cyanotic, and 
there are early indications of heart failure. Rest- 
lessness and anxiety are present from the start, and 
may give place later to delirium. There is a gen- 
eral perspiration, and the extremities are cold. 
The pulse is 80 to 100 to the minute, while the 
temperature is rarely above 101° to 103° F. The 
sputum contains mucus, pus, and fibrinous casts of 
the tubes. The digestive functions are impaired, 
the tongue is furred, and the bowels are consti- 
pated. 

Physical Signs: — Inspection. As before stated, 
the patient is usually a child or an aged individual; 
there is an expression of anxiety or distress, the 
face being bloated and livid, the alse nasi dilated, 
the respirations labored, and dyspnea, which may 
amount to an orthopnea, is present. The patient is 
restless, and there is an abnormal distension of the 
upper part of the chest. 



ACUTE BRONCHITIS OF THE SMALLER TUBES. 53 

Palpation: — The pulse is weak and rapid; early 
in the course of the disease the surface of the body 
is hot, while later it is covered with cold clammy 
perspiration. 

Percussion: — This may reveal a normal percus- 
sion note, but more frequently there is a hyper- 
resonance over the upper lobes, due to a compen- 
sating emphysema, on account of the closure of 
many small bronchi. 

Auscultation: — In addition to the signs of bron- 
chitis of the larger tubes there are heard, bilater- 
ally, abundant sibilant rales which are replaced later 
by subcrepitant rales. 

Complications and Sequelae: — The most frequent 
are broncho-pneumonia and atelectasis. 

Diagnosis : — This is based upon the S3^mmetrical 
distribution of the fine rales, absence of percussion 
dullness, the rapid respiration, cyanosis, feeble rapid 
pulse, clammy sweats, and the feeble respiratory 
murmur. Should the disease progress and broncho- 
pneumonia follow, the symptoms are all intensified. 

It should be differentiated from miliary tubercu- 
losis and edema of the lungs. 

CAPILLARY BRONCHITIS. MILIARY TUBERCULOSIS. 

1. This is a brief disease of 1. A more prolonged disease 
the very young and aged. of the young and adults. 

2. Early in the case dyspnea, 2. These are not as marked 
cyanosis and constitutional early in the case, 
depression are marked. 

3. The fever is moderately 3* The fever is intense and 
high. vacillating. 

4. Percussion resonance is 4- There are localized areas of 
vesicular but there may be of persistent dullness w^hich 
spots of impaired resonance. are follow^ed by moist rales 

and softening. 

5. Many cases recover. 5. Is progressively fatal. 



54 ACUTE BRONCHITIS OF THE SMALLER TUBES. 

Cases of pulmonary edema have been mistaken 
for capillary bronchitis, but it should be remem- 
bered that edema is seldom confined to the lungs, 
and when it is, it is dependent on the heart, and 
should be easily recognized in either case. 

P 7^0 gnosis : — The prognosis should always be 
guarded as a large percentage of these patients die. 
The signs of special gravity are an increasing dys- 
pnea with lividity, delirium, and coma; the expec- 
toration having ceased the patient sinks down in 
bed, and lies on one side with the head low and 
bent forward. Infants may succumb in twenty-four 
hours; children survive a little longer; adults ad- 
dicted to alcohol may die in four days; while in 
the aged the period is still shorter. 

Treatment : — The temperature of the room in 
which the patient is kept should be uniform, and 
maintained at about 72 °F.; the ventilation should 
be good and the air kept moist by a vaporizer. 
The position of the patient must be changed from 
time to time, that the secretions may not be al- 
lowed to gravitate to one side wholly. Should the 
secretions become profuse the patient should be 
placed with the head and chest lower than the 
remainder of the body, as this position favors the 
expulsive efforts when coughing, allowing the secre- 
tions to escape more readily. 

The diet must be such as will maintain the 
patient's strength. It should consist of fluid to a 
great extent. Milk, if well borne, is excellent, 
but it should be given warm. Nourishing soups, 
gruels, broths, eggs beaten up, custards, light pud- 
dings, are all good. If the tongue is clear, a piece 
of chicken, fish, or meat may be allowed. As con- 



ACUTE BRONCHITIS OF THE SMALLER TUBES. 55 

valescence takes place the diet should be nutritious 
but carefully adapted to the capacity of the diges- 
tive organs. The patient should have an abundance 
of water, and yet care should be taken that the 
stomach is not disturbed by food or gas, as either 
one will interfere with respiration. The bowels 
should not be allowed to become constipated; if 
regulation of the diet is not sufficient to accom- 
plish this, an enema or a glycerine suppository will 
usually do the work. The chest must be protected 
with a cotton jacket or a soft flannel shirt. It is 
seldom that appHcations and poultices are demanded, 
but when there are sharp pleuritic pains hot appli- 
cations will bring relief. 

An emetic is of service when there is debility 
of the bronchial muscles and the secretions are 
retained. This is indicated by the rales continuing 
after a cough. Emesis may be accomplished by 
the use of ipecacuanha or zinc sulphate. 

Where there are indications of failure of the 
respiratory organs, of cyanosis with livid skin, and 
drowsiness is rapidly appearing, give the patient a 
hot bath Too° to iio^F., protecting him afterwards 
from exposure. When the pulse becomes small, 
weak and irregular, alcoholic stimulants will benefit 
the case; should the suffocation and respiratory fail- 
ure become severe, inhalation of oxygen must be 
given often and regularl}^ 

Belladonna: — This remedy should be studied 
early in the history of the case, when the fever is 
high. The child may have had a convulsion; the 
skin is red, hot, and inclined to be moist; the pupils 
are dilated; the carotids are throbbing; the breath- 
ing is irregular and hurried; the cough is dry, dis- 



56 ACUTE BRONCHITIS OF THE SMALLER TUBES. 

tressing, spasmodic, and attended with but little or 
no expectoration; and the child cries after each 
paroxysm. The patient is drowsy, does not sleep, 
but starts frequently, just as he appears to be going 
to sleep. 

Tartarus emeticus: — Although other remedies 
may have been indicated earlier in the case, this is 
frequently the one demanded when the physician is 
called. The nostrils are dilated, flapping, and there 
is a dark soot}^ appearance inside of each nostril. 
The eyes are drows}/, and rales are heard all over 
the chest. There is but little material expectorated; 
at times there is nausea and gagging. When this 
remedy, although apparently indicated, does not 
control the cough, study hepar sulphur. When the 
dyspnea and cj^anosis are most pronounced study 
the arseniate of antimony. 

Ferrum phosphoricum: — In children this is fre- 
quently the remedy early in the disease. The 
cough is spasmodic and painful; the face is con- 
gested, and there is fever; the pulse is soft and 
compressible. There are rales through the chest. 

Lycopodium : — This remedy is to be remembered 
in those who are emaciated, who take cold easily, 
and have derangement of the alimentary tract. 
They have great flatulency, and, though hungry, 
a very few mouthfuls of food satisfies on account of 
the gaseous distension of the stomach. The food 
that is taken soon sours. The feet are cold and 
there is a general aggravation of all the symptoms 
from 4 to 8 p. m. The patient is one in whom 
the intellect is keen, but the muscular S3'stem is 
weak, and he is subject to derangement of the urin- 
ary, digestive, and respiratory systems. The com- 



ACUTE BRONCHITIS OF THE SMALLER TUBES. 57 

plexion is sallow. The cough sounds loose, but 
there is but little expectoration. 

Ipecacuanha: — When this remedy is indicated 
there is nausea, the child coughs, gags, and suffo- 
cates; there is a coarse rattling in the chest, the 
face is pale, has a sickly appearance, and an anxious 
look. The symptoms under this remedy, while they 
resemble tartar emetic, come on much more sud- 
denly, and present the acute stage, while those of 
tartar emetic come on more slowly. 

Veratrum album: — This is a neglected remedy in 
pulmonary diseases. It should be remembered in 
the second stage of these diseases, when there is a 
great quantity of mucus in the bronchial tubes that 
cannot be coughed up; there are also wheezing and 
coarse rales, but no expectoration in spite of the de- 
pressing paroxysms of coughing, which are worse 
at night and are attended with cerebral congestion. 
There is a cold perspiration on the forehead, with 
fainting and great prostration; the face is blue and 
there is great anguish. 

Antimonium arsenicum: — This remedy is used 
by some when tartar emetic has failed. There is 
great dyspnea with cough in cases of emphysema 
complicated with bronchitis. 

Lachesis: — This remedy, with naja, should be 
studied in cases of cough that are secondary to 
heart lesions. There is coughing as soon as the 
patient falls asleep, with choking, as if suffocation 
would take place. He is always unhappy and dis- 
tressed after sleep. The throat is exceedingly sen- 
sitive to pressure. 

Laurocerasus : — When this remedy is indicated 
there is rapid sinking of the forces, lack of energy. 



58 ACUTE BRONCHITIS OF THE SMALLER TUBES. 

want of reaction, and painlessness with all the com- 
plaints. There is cough with whistling sounds as 
though the mucous membrane were dry, or as if 
mucus were hanging from the throat and could not 
be raised; with spasmodic oppression of the chest 
as though the lungs could not be expanded. 

Strychnium 2x: — This drug will be required in 
some cases, where there are indications of cardiac 
and respiratory failure. 

Caffeinum: — This will be found serviceable in 
many cases similar to the above but of a more 
serious nature. It may be used hypodermatically 
in doses of from one to two grains, as demanded. 



CHAPTER VIII. 
CHRONIC BRONCHITIS. 



Definition: — This is a chronic catarrhal inflam- 
mation of the mucous membrane of the bronchial 
tubes. 

Etiology: — It is most frequently observed in 
those of middle and advanced years, who have been 
subject to repeated attacks of acute bronchitis. In 
some cases it is chronic from the beginning, and in 
others it is associated with pulmonary tuberculosis, 
emphysema, asthma, gout, rheumatism, alcoholism, 
adenoids, and renal and cardiac diseases, especially 
mitral stenosis. 

Pathology: — The bronchi of both lungs are in- 
volved in the change. The mucous membrane is 
often greatly thickened, and we find a marked pro- 
liferation of the epithelial cells. A true hypertrophy 
is present in some cases, while in others there is 
atrophy of the mucous, sub-mucous and muscular 
coats, so that the bronchial tubes become dilated, 
giving rise to bronchiectasis. In other cases the 
mucous membrane is irregularly thickened and in- 
filtrated, while the cartilages undergo a fatty degen- 
eration, and dilate as a result of the strain from 
coughing. Emphysema commonly follows chronic 
bronchitis, and narrowing of the bronchus, due to 
sclerotic changes, is not uncommon. 

Symptoms : — They develop graduall}^ and are 
most marked during the winter. Many of the 
symptoms are similar to those of the acute form, 



6o CHRONIC BRONCHITIS. 

but are usually less severe and run a chronic course. 
The cough is most severe early in the morning and 
is due to the secretions in the tubes, vv^hich produce 
the irritation and compel the patient to cough until 
the exudation is dislodged, raised and expectorated. 
In cases of dry catarrh, the cough is hacking, dry, 
paroxysmal, and the expectoration is tenacious, or 
blood streaked. The sputum is often abundant and 
purulent. At times there is a certain amount of 
dyspnea associated with pain in the chest and op- 
pression over the sternum. When the bronchitis is 
the result of cardiac or renal diseases the dyspnea 
may be marked; and if the result of cardiac disease 
the expectoration may contain considerable blood. 
There is seldom any increase in temperature, but 
should this occur it generally manifests itself by a 
slight fever towards night. The appetite usually 
remains good w^ith little if any loss of flesh. 

Physical Signs: — Inspection. Apart from the 
dyspnea that is present at times, this does not give 
much information. 

Palpation : — Should there be large accumula- 
tions of fluid in the bronchial tubes the vocal frem- 
itus may be diminished. Should there be a small 
quantity of fluid in the large tubes, a bronchial 
fremitus or rhoncus may be felt. 

Percussion: — As a rule the percussion note is 
normal. When emphysema exists as a complication 
hyper-resonance is easily excited. 

Auscultation: — This reveals all forms of rales, 
both moist and dry. They are most marked in the 
lower part of the lung, and heard best posteriorly, 
usually bilaterally, except in those cases that result 
from influenza which is often unilateral. 



CHRONIC BRONCHITIS. 6l 

VARIETIES OF CHRONIC CATARRH. 

Dry Bronchitis : — In this form the expectoration 
is small in amount and tenacious, or it may be 
absent. Auscultation reveals dry rales. Emphy- 
sema and attacks of asthma are the most common 
complications. 

Broiicliorrliea: — In this variety there is an ex- 
cessive amount of secretion. The expectoration 
may be thin and watery, transparent and rop}^ or 
purulent, and varies in quantity from one to two 
pints in twenty-four hours. When allowed to stand 
it separates into three layers, an upper of frothy 
mucus, a middle of thin watery fluid, and a lower 
one of viscid, purulent, or cellular substances. Em- 
physem.a and bronchiectasis are the most frequent 
complications. There is dyspnea and a cough 
which is often persistent and paroxysmal. Occa- 
sionally there is but a single coughing spell each 
niorning, the secretion being thus removed. 

Fetid Bronchitis : — In this variety the secretion 
undergoes decomposition and emits a foul odor. It 
is chronic and usually associated with bronchiectasis, 
but may arise during the course of other diseases 
The general health shows impairment, and is asso 
ciated with cough, irregular fever and occasional 
chills. The foul odor of the breath and expectora 
tion is characteristic, while broncho-pneumonia, gan 
grene, and clubbing of the fingers often result. 

Complications and sequelce : — The most frequen 
are emphysema, asthma, bronchiectasis, atelectasis, 
phthisis, congestion of the liver, and interstitial 
nephritis. 

Diagnosis: — This is based upon the clinical his- 
tory of the case and the physical signs. 



62 CHRONIC BRONCHITIS. 

It must be differentiated from interstitial pneu- 
monitis and pulmonary tuberculosis. 

CHRONIC BRONCHITIS. INTERSTITIAL PNEUMONITIS. 

1. Chest retains its normal i. Undergoes retraction. 
shape. 

2. If there is any impairment 2. Impairment of resonance is 
of resonance it is general. circumscribed and decided. 

CHRONIC BRONCHITIS. PULMONARY TUBERCULOSIS. 

1. The Physical signs are i. Are localized, at least at 
general. first. 

2. Impaired resonance not 2. Is more marked, 
marked. 

3. Temperature but little ele- 3. Fever typical, 
vated. 

4. Tubercle bacilli not found. 4. Are present in the sputum. 

Prognosis: — This disease is seldom, in itself, a 
cause of death. When secondar}' changes take place 
an absolute cure is impossible. The dilatation of the 
right heart and broncho-pneumonia are to be feared. 
Treatment : — In the management of these cases 
attention should be devoted to the prevention of 
exacerbation and secondary changes so far as possi- 
ble. In all cases the constitution of the patient 
should be taken into consideration in order to ascer- 
tain if there is any tendency to gout, tuberculosis, 
renal or cardiac disease; as it may modify the 
treatment. If possible, these patients should winter 
in a mild climate, where the temperature varies but 
a few degrees. Those who are unable to make 
this move should introduce such reforms in living as 
will fortify them against severe atmospheric changes, 
and should wear woolen next to the skin the year 
round. 



CHRONIC BRONCHITIS. 63 

The back and chest should be bathed in cold 
water each morning, each sponging to be followed 
by a thorough friction. Chest protectors are not to 
be advised if they can be avoided. Attention 
should be devoted to the feet that they be kept 
dry and warm. The house should be well ven- 
tilated and kept at a temperature of from 68° to 
70° F. 5 while the atmosphere in which the patient 
works should be pure and dry as possible. Expos- 
ure should be avoided and on damp cold days the 
patient should remain in the house. Great care 
should be taken to avoid draughts, badly ventilated 
or poorly heated rooms, and exposure, especially 
v^hile perspiring. If the patient is obliged to be 
out during very damp weather he should wear a 
respirator or woolen muffler over his mouth, and 
should breathe through his nose. 

The diet should be simple but nutritious and 
taken at regular intervals; in those cases where 
gout or rheumatism is present it may be necessary 
to modify the diet. If there is a weakness of the 
system and a tendency to tuberculosis, cod liver oil, 
taken during the fall and early winter, will be 
found to fortify the system against these attacks. 
The exercise taken should be sufficient to keep the 
organs in a normal condition. A systematic pul- 
monary exercise, apart from any general exercise, 
will benefit many cases. 

If a change of climate is being considered it 
should be remembered that a warm and rather re- 
laxing cKmate will be most serviceable to those with 
a chronic catarrh, while if there is a profuse ex- 
pectoration, a high dry climate will be required. If 
the disease has been of long duration the vitality is 



64 CHRONIC BRONCHITIS. 

lowered and the patient must be built up. The 
liver, kidneys, skin and bowels must be carefully 
regulated, requiring a combination of medicinal^ 
hygienic, and climatic influences to produce a 
favorable result. 

Manual compression applied on the external 
surface of the thorax and abdomen during expira- 
tion will be found of service in producing free ex* 
pectoration and assisting the air passages in unload- 
ing their secretions. 

In many of these cases in*halations are beneficiaL 
In the dry catarrh, a ten per cent solution of bicar- 
bonate of soda or sodium chloride is of service. 
When the secretions are abundant, inhalations of 
eucalyptus or turpentine are of service; while in 
fetid bronchitis, a three to five per cent solution of 
carbolic acid, or a one to one thousand solution of 
thymol used in a steam atomizer will control some 
of the fetor. This form of treatment should be em- 
ployed for about five minutes at a time and from 
four to five times a day. In selecting a remedy 
the disease underlying the bronchitis should always 
be taken into the totality of the case. Nearly any 
remedy may be called for, and the physician will 
find that if it is given in simple syrup it will 
often meet the patient's desire for a cough S3^rup. 

lodium: — This remed}^ should be studied in those 
cases where there is a tendency to tuberculosis. 
The cough is dry, hacking, and fatiguing and is 
attended with but little expectoration. There is 
great debility and emaciation even while living well. 
The patient usually has dark or black hair and 
eyes, and there is hypertrophy and induration of 
the glandular tissue. It may be used internally or 
by inhalation. 



CHRONIC BRONXHITIS. 65 

Antimonium iodatum: — Bronchitis with humid 
asthma in cases that have a similarity to tubercu- 
losis. There are frequent spells of spasmodic cough- 
ing which are worse during the morning and at 
night, with free expectoration of a muco-purulent 
material of a sweetish taste. There is rapid loss of 
appetite and strength. The tongue is coated and 
there is nausea with a disgust for food. The skin 
and conjunctiva are of a yellowish color. 

Stannum iodatum: — This remedy should be 
studied when the expectoration is of a dense muco- 
purulent character, sweetish, or salty to the taste. 
There is extreme exhaustion of the mind and body, 
with a sinking, all-gone sensation in the stomach. 
There is also great weakness of the chest, so weak 
that the patient cannot talk. The cough is deep, 
hollow, strangling, and is preceded by a hoarseness, 
and deep husky voice. 

Kali bichromicum: — This remedy is indicated 
in chronic bronchitis of recent origin, before the 
secondary changes have taken place. There is 
cough with expectoration of tough stringy mucus. 
The whole respiratory tract is involved in the 
catarrhal process. The expectoration appears to be 
loose, but it sticks to the parts and is drawn out 
into long strings of an opaque white mucus. It 
should be compared with senega. 

Senega: — This remedy is adapted to the aged, 
with a relaxed condition of the system. The pro- 
cess is of longer duration than in the last remedy 
so that in connection with the chronic catarrhal 
bronchitis, the secondary changes are present, as 
emphysema, bronchiectasis, and at times ascites and 
anasarca. There is great rattling of mucus in the 



66 CHRONIC BRON'CHITIS. 

bronchial tubes, accompanied by a loose, rattling 
cough, though but little is expectorated, and that 
is tough and has but little elasticity about it. 
There is a sensation of burning in the chest, which 
is painful and sore, accompanied with a tendency 
to diarrhea. It gives the best results when used in 
five-drop doses of the tincture. 

Pulsatilla: — This remedy is indicated in the 
second -stage of catarrhal bronchitis, when the cough 
is loose during the day, and at night the expectora- 
tion is profuse, yellow or whitish in color, and of 
a salty taste. The patient is usually an anemic 
female of the lymphatic type with blue eyes; of a 
yielding, tearful disposition. The symptoms are all 
worse in a close room, and relieved in the cool air. 
The symptoms change rapidly; the patient is well 
one hour and sick the next; complains of feeling 
chilly, associated with coldness and paleness of the 
skin. There is a bad taste in the mouth during the 
morning, with a yellow or whitish coating upon 
the tongue. The stomach is easily deranged by the 
use of rich, fat, food. If the patient is a female 
the menses are delayed and scanty; while with each 
paroxysm of coughing, there is an emission of 
urine. 

Sulphur: — This is an important remedy in 
chronic bronchitis of long standing where there are 
no secondary changes. The patient is sensitive to 
the least atmospheric change, even if he is in no 
way exposed. The cough is either attended with 
an expectoration of large quantities of stringy white 
mucus, or with a scant yellow sputum. The patient 
suffers much from hot flushes and faintness; com- 
plains of heat on top of the head, burning of the 



CHRONIC BRONCHITIS. 67 

palms of the hands and soles of the feet; feels suf- 
focated and desires that the doors and windows be 
opened. He is troubled with morning diarrhea; 
again constipation may be present, with great strain- 
ing to evacuate the stool. All secretions are acid 
and the symptoms are often aggravated about 1 1 
a. m. 

Ammonium muriaticum: — This is a valuable 
remedy in the chronic bronchial catarrh of the 
aged, and in fat, sluggish and bloated individuals, 
where the secondary changes, as bronchiectasis and 
emphysema are present. Palpation and auscultation 
reveal the presence of mucus in the bronchial tubes, 
while but little is expectorated. The cough sounds 
loose and the expectoration is thick and of a white 
color. 

Eucalyptus: — This remedy may be used either 
by means of the spray, vapor, or internally. In 
the chronic bronchitis of the 'aged, and those who 
are enfeebled, anemic, and are having night sweats 
with loss of appetite and weight, it is of service. 
The respirations are quickened, the cough is ac- 
companied by a free expectoration of white, thick 
material which may become muco-purulent, and at 
times fetid. 

Phellandrium: — This remedy is adapted to per- 
sons of a feeble, irritable, lymphatic constitution, with 
weak and defective reaction, who suffer from a 
chronic bronchial catarrh, with more or less profuse 
expectoration. The cough returns and increases 
during the cold seasons of the year, and only abates 
upon the return of warm weather; it is continuous 
for an hour or more early in the morning, and is 
accompanied by dyspnea and prostration; the cough 



68 CHRONIC BRONCHITIS. 

at night is not relieved by sitting up. The second- 
ary changes, as emphysema, and dilatation of the 
right heart, have often taken place. There are 
coarse rales; the respirations are short; cough con- 
tinues at times, day and night; there being great 
thirst with loss of appetite and sleeplessness. It 
should be studied during the last stage of pulmo- 
nary tuberculosis when the expectoration is very 
offensive. 

Copaiva: — This is to be thought of in disease of 
the bronchial tubes with profuse muco-purulent dis- 
charges that are easily expectorated and are very 
offensive. 

Balsamum peruvianum: — In cases of chronic 
bronchial catarrh of old people, where there is de- 
bility, a slow, feeble circulation, and a loose rattling 
cough. The expectoration is thick, yellow, or 
green, having a fetid odor. There is apt to be 
a catarrhal condition of the nares and larynx. The 
latter may simulate tuberculosis. 

Sabal serrulata: — This remedy should be studied 
in cases of bronchorrhea of the aged, when associ- 
ated with prostatic and urinary difficulties. 

Aconitum: — This remedy is seldom indicated in 
a chronic condition, and yet there are cases, in 
those of a full plethoric habit, when it is demanded. 
The cough is dry, spasmodic, and attended with 
dyspnea; is worse at night and causes restlessness. 

Bryonia: — When there is a rheumatic element 
in the case. The cough is dry and causes the 
patient to assume the sitting posture; but this 
makes him faint and nauseated. There are pains 
in the chest when coughing which cause him to 
support the sides with his hands. The lips are 



CHRONIC BRONCHITIS. 69 

dry, there is thirst for large quantities of water, 
and an aggravation from motion. 

Carbo vegetabilis: — In the aged when there is 
a chronic catarrh of the bronchi and stomach. 
The secretions are foul, the patient complains 
about the lack of air, and all foods disagree. 
There is great accumulation of gas in the stomach 
and bowels, so that, when eating or drinking, 
there is a sensation as if the stomach or abdomen 
would burst. There is coldness of the breath and 
whole body. The expectoration is profuse and 
fetid. There is emphysema with dilatation of the 
right heart, and a catarrhal gastritis. 

Lycopodium: — There is great accumulation of 
flatulence in the stomach and bowels with a con- 
stant sensation of satiety, the least morsel of food 
causing a -feeling of fulness that extends to the 
throat, accompanied with a constant fermentation 
in the abdomen. The bowels are constipated. 
The urine is filled with urates. The cough is 
loose and rattling accompanied with difficulty in 
breathing. All the symptoms are worse from 4 
to 8 p. m. 

Sepia: — The cough is usually dry but there 
may be a copious expectoration of a white salty 
mucus or pus. This remedy must be chosen on 
the general symptoms. The urine has a putrid 
odor and deposits a reddish or clay-colored sedi- 
ment that adheres to the vessel as if burnt on. 
In the female there is a sensation as though the 
pelvic organs would protrude through the vulva; 
so that she crosses her limbs to prevent it. The 
bowels are constipated and there is a yellow 
saddle across the nose. 



70 CHRONIC BRONCHITIS. 

Tartarus emeticus: — This remedy is of service 
when there are acute exacerbations of the chronic 
bronchial condition, and when emphysema, and 
other chronic lung diseases, are present. The 
cough is loose and rattling in the tubes, yet it 
is expectorated with difficulty. On account of the 
interference in the lung, the blood is imperfectly 
aerated and cyanosis is present. 

Ipecacuanha: — This remedy is of most service 
in acute bronchitis, especially of children when 
there is the constant nausea, but vomiting gives 
no relief. It is also of service in the more chronic 
cases when asthma appears as a complication and 
the cardinal symptoms are present. 

Grindelia robusta: — When with the chronic 
bronchitis there are attacks of dyspnea and asthma. 
The dyspnea is dependent on an accumulation of 
mucus in the smaller bronchi, but in spite of the 
mucus in the tubes the cough is dry, and the 
expectoration slight or absent. The bronchitis 
may follow pneumonia, in which case the expec- 
toration is muco-purulent. The patient dreads 
going to sleep on account of a loss of breath 
which wakens him. 

Spongia tosta: — This remedy is indicated when 
there is a laryngo-tracheal catarrh associated with 
the chronic bronchitis. The cough is croupy, dry, 
hard, tight, hollow, and accompanied with hoarse- 
ness and loss of voice. There is great dryness 
of the larynx, and little or no expectoration. 

Phosphorus: — When there are deep-seated 
organic affections in thin, feeble patients, with a 
tendency to fatty degeneration, this remedy should 
be studied. There is a sensation of weakness, and 



CHRONIC BRONCHITIS. 7 1 

emptiness in the abdomen. The cough is hard, 
tight, dry, and rough, with burning between the 
shoulders, and a tendency to hemorrhages. The 
feet and legs are cold, with a cold, clammy per- 
spiration. The patient takes cold easily and is 
very sensitive to cold air. 

Rumex crispus: — This remedy is indicated when 
there is a hyper-aesthesia of the mucous membrane 
of the larynx, and especially the trachea. There 
is a violent incessant cough that is dry and 
fatiguing, with but little expectoration. The point 
of irritation is in the suprasternal fossa; pressure 
at this point, talking, and inspiring cold air, all 
aggravate the cough. 

Sanguinaria canadensis: — When in the sub- 
acute and chronic form of bronchitis, the large 
bronchial tubes are involved, the stage of mucous 
secretions is reached, and the sputum is raised 
with difficulty. There is a circumscribed redness 
of the cheeks, with an afternoon fever. There is 
emptiness of the stomach, that is worse after eat- 
ing. There is a constant tickling of the larynx, 
or a crawling sensation extending down behind 
the sternum which causes a cough. The chest is 
sore and painful to the touch, accompanied with a 
desire to take a deep breath, which when taken 
causes a pain in the side. 

Chelidonium majus: — This is a grand remedy in 
many acute cases and also in chronic ones when 
there are associated affections of the liver, and a 
gastro-duodenal catarrh. There is a constant pain 
in the inner side of the inferior angle of the right 
scapula, accompanied with stitching pains in the 
hepatic region, that are worse from motion and 



72 CHRONIC BRONCHITIS. 

deep breathing. The cough is worse during the 
morning, when there is much rattling of mucus in 
the bronchial tubes, which is raised with difficulty. 

Silicea: — This remedy is only secondary to sul- 
phur in chronic bronchitis where there is a deep- 
seated organic cause for the disease. There is 
lack of vitality so that the patient cannot keep 
warm even while exercising, and takes cold from 
the slightest draught or exposure. There is marked 
perspiration about the head and chest, and women 
always complain of coldness during the time of 
the menstrual period. There is a tendency to sup- 
puration. The cough is loose, racking, and suffo- 
cating, with a copious expectoration of thick 
yellow or greenish pus, which is accompanied with 
a hectic fever, great debility, and profuse night 
sweats. 

Hepar sulphur: — When the acute stage is 
passed, the cough has become loose and rattling, 
and the respirations are hoarse and wheezing, 
with soreness of the chest, this remedy should 
be studied. There is a great tendency to take 
cold. Sour sweats all the time, especially about 
the chest. The patient cannot bear to be un- 
covered as it makes the cough worse. 

Hyoscyamus: — The patient is irritable, nervous 
and hysterical. The cough is dry, spasmodic, 
worse when lying down, and relieved by sitting 
upright. There is a tickling in the throat as 
though the uvula were too long and the par- 
oxysms are so severe at times that the cough- 
ing becomes almost suffocating. 

Ambra grisea: — This remedy produces a cough 
which is reflex in origin, the point of irritation 



CHRONIC BRONCHITIS. 73 

being either spinal, ovarian or uterine. It is 
observed in hysterical women with a constant 
hacking cough, scraping, and with an expectoration 
in the morning but none at night. The patient is 
lean, thin, sickly and takes cold easily. 

Lactuca virosa: — This remedy produces an in- 
cessant, spasmodic cough, which threatens to burst 
the chest, it is so severe. The cough is produced 
by a tickling in the fauces and is attended with a 
sense of suffocation in the throat. The coughing 
is dry and comes in paroxysms that rack the chest 
and is felt in the occiput. 

Acidum benzoicum:— This remedy or some one 
of its compounds is at times indicated in bronchial 
catarrh where the general urinary symptoms pre- 
dominate. 

Mercurius iodatus flavus (protoiodide): — This is 
a valuable remedy in those suffering from second- 
ary syphilis, and also scrofulous patients, in which 
the bronchial tubes are coated with a muco-puru- 
lent material. The cough is loose and rattling. 
The nares and pharynx are also involved in the 
catarrhal process. The parotid and cervical glands 
are enlarged, and the tonsils are enlarged and in- 
flamed. 

Calcarea carbonica: — In scrofulous patients 
where there are increased mucous secretions and 
a tendency to take cold easily, this is the first 
remedy to study. There is coldness of the ex- 
tremities, the feet feeling as though he had on 
damp stockings. There is frequently a sensation 
of inward coldness, with a hoarseness that is 
worse during the morning. The expectoration 
consists of a thick yellow, sour mucus; or it may 



74 CHRONIC BRONCHITIS. 

be bloody with a sensation of soreness in the 
chest. The chest is sensitive to the touch, per-^ 
cussion or pressure. There are suffocating spells, 
made worse by climbing stairs. 

Kali iodatum: — This drug is indicated in cases 
of chronic bronchitis where there is a syphilitic 
history. There is a profuse watery, acrid coryza, 
with a violent cough that is worse in the morn- 
ing; the expectoration being greenish, or like soap 
suds. The larynx feels raw and the cold travels 
down the chest. There are stitching pains through 
the lung to the back, while pulmonary edema is 
threatening. 

Drosera: — The action of this remedy is upon- 
the respiratory organs to a great extent. There is 
a spasmodic dry cough, the paroxysms following 
each other so rapidly that the patient can hardly 
get his breath, and he chokes and vomits. The 
cough is deep and hoarse, and is worse after mid- 
night. The expectoration is of a yellow color,. 
There may be bleeding from the nose and mouth- 
There is hoarseness with deep hoarse voice and a 
sensation of scraping, and roughness deep in the 
fauces. He is worse from lying down, from the 
warmth of the bed, and after midnight. 

Arsenicum iodatum: — This should be studied 
when the discharge is irritating and corroding ta 
the surface over which it flows, so that the mucous 
membrane is always red, swollen, itching and burn- 
ing. The cough is hoarse, racking and attended 
with a profuse expectoration of a purulent nature; 
there is cardiac weakness, emaciation and general 
debility. 



CHRONIC BRONCHITIS. 75 

Arsenicum album: — The great characteristic of 
this remedy is the pronounced exhaustion after 
the slightest exertion. There is great anguish and 
restlessness, so that the patient changes position 
continually, has great fear of death, and feels that 
it is useless to take medicine. He is unable to lie 
down as he fears suffocation. It should be remem- 
bered in cases of fetid bronchitis of the aged, 
when there are asthmatic attacks, worse after mid- 
night, and from cold drinks and foods, while re- 
lieved by heat and having the head elevated. 



CHAPTER IX. 
FIBRINOUS BRONCHITIS. 



Synonyms :— F\3.stic bronchitis, croupous bron- 
chitis, mucous bronchitis. 

Defifiition: — This is a disease characterized by 
an exudation of a plastic fibrinous material which 
forms casts within the bronchi. 

Etiology: — It is a rare affection; occurring 
twice as often among males as females, and 
while it may be found at any age, it is most 
frequent in those from fifteen to forty years of 
age. It is most prevalent during the spring 
months, cold and wet weather predisposing. It 
is said to be epidemic at times, and a heredi- 
tary tendency is present in some cases: It may 
be associated with pulmonary tuberculosis, valvu- 
lar heart disease, pneumonia and typhoid fever; 
though, while the above are all recognized as 
predisposing causes, its real cause is not known. 

Pathology : — This is not definitely known, but 
it is independent of diphtheria, and as yet no 
particular bacteria has been demonstrated as the 
exciting cause. The exudation may be present 
in a few of the tubes, or it may be scattered 
through different portions of both lungs. The 
cast formed is tubular, and although it does not 
block the larger tubes, it frequently does the 
smaller. The cast expectoration may be in frag- 
ments, or it may be of the whole bronchial tree, 
and from six to seven inches in length; of a 



FIBRINOUS BRONCHITIS. 77 

white or gray color, and occasionally stained with 
blood. The composition of the cast is fibrinous, 
and is identical with that met with in other croup- 
ous exudates. 

Syviptoms : — These cases may assume an acute 
or chronic form. As the exudate into the bronchi 
takes place, dyspnea appears and may be said to 
be in proportion to the extent of the bronchial 
area affected. 

The acute form, which is rare, may begin with 
a chill, which is followed by fever, dyspnea, sub- 
sternal constriction, and severe paroxysms of 
coughing. It is either attended with the expulsion 
of the cast, hemorrhage, free expectoration, and 
relief of the symptoms; or the dyspnea becomes 
more severe and a fatal asphyxia results. In the 
chronic form the attacks are less severe than in 
the acute form, and recur at irregular intervals. 
A single attack always entails a liability to the 
disease throughout life, although the attacks may be 
far apart. These cases present many of the symp- 
toms of ordinary bronchitis with or without fever. 
The cough becomes paroxysmal in character, and 
the expectoration is in the form of rounded masses; 
which, unraveled, are found to be true molds of 
the affected tubes. There may be a slight hemor- 
rhage. The interval betVv^een the attacks may be 
of any duration from a week to a year. 

Physical signs: — These vary with the extent 
of the disease and the amount of the tube in- 
volved. The tactile fremitus, local expansion, and 
respiratory murmur are diminished over the af- 
fected part of the lung. There is dullness upon 
percussion, over the diseased areas and hyper- 



78 FIBRINOUS BRONCHITIS. 

resonance over the healthy part. As the cast is 
dislodg-ed these signs disappear. 

Complications and Sequelce: — The most frequent 
are a general bronchitis, broncho-pneumonia and 
pulmonary phthisis. 

Diagnosis: — This is based upon the fact that 
fibrinous casts of the bronchi are expectorated, and 
can be seen as such when floated out on water; 
they must be differentiated from those due to 
diphtheria by a bacteriological examination. 

Prognosis : — The acute form is frequently fatal, 
while the chronic form, although persistent, is sel- 
dom fatal. 

Treatment : — These patients should be well nour- 
ished to withstand the extra task imposed on them 
by the disease. In the chronic form everything 
possible should be done to improve the general 
health; sea voyages and change of climate are 
often serviceable. In the acute form inhalation of 
vapors of or nebulous vapors containing iodine, 
creosote, lactic acid, and lime water, with the ap- 
plication of dry heat to the chest have been thought 
to assist in softening the casts. 

The intratracheal injection of a teaspoonful of 
glycerine several times daily has aided in the 
separation of the cast in some cases. The reme- 
dies that are of service here are much the same 
as those used in croupous laryngitis. Pilocarpine 
has been employed; also emetics when cyanosis is 
marked. 

Kali bichromicum: — This remedy produces a 
membrane that involves the larynx, trachea, and 
bronchi. The patient is of the fat, light-haired 
type who suffers from catarrhal, syphilitic, or 



FIBRINOUS BRONCHITIS. 79 

psoric affections; he is fat, chubby, and incHned to 
take cold in the open air. The cough is violent, 
hoarse, metallic, and attended with rattling and 
gagging from viscid mucus in the throat; the ex- 
pectoration consists of a tough mucus, and fibres 
of elastic casts. 

Bromium: — This remedy should be studied 
v^hen the patient is of the blonde type with light 
blue eyes, flaxen hair, delicate skin, and is scrof- 
ulous. Its poisoning shows that it affects the 
bronchi as well as the larynx and trachea. It 
produces great dyspnea, the patient cannot inspire 
deeply enough; it is as if breathing through a 
sponge; or as if the air passages were full of 
smoke or vapors of sulphur. There are sawing, 
dry sounds. Inhalation of the second or third 
decimal on cotton wool is often of more service 
than the internal administration. It should be 
freshly prepared. 

lodium: — This remedy will be found most fre- 
quently indicated in those of a scrofulous diathe- 
sis, with dark hair and eyes. There is a dry 
cough accompanied with wheezing and sawing 
respirations, which are short and quick. The 
countenance is pale; the skin is cold, and covered 
with a clammy perspiration; the pulse is weak, 
small and rapid. 

Spongia tosta: — This remedy acts most favor- 
ably in those with light hair and fair complexions. 
The cough is dry, hacking, rasping, ringing, wheez- 
ing and whistling; everything is dry; no moist 
rales. The respirations are harsh and sawing. 

Acidum Aceticum: — This remedy is adapted to 
persons with a pale, waxy face, who are lean. 



8o BRONCHIAL STENOSIS. 

with lax fibre. There is cough and all the indi- 
cations of membranous formation. .Inhalation of 
the vapar. of cider vinegar is of service in these 
cases. 

Phosphorus: — This remedy is of service in the 
typical cases, to assist the absorption of the exu- 
date. 

Belladonna: — This has been employed during- 
the early stages of the acute form. 

Aconitum: — This remedy will control the violent, 
spasmodic cough, and when indicated will pre- 
vent exudation from taking place. 



BRONCHIAL STENOSIS, 

Definition: — This is a narrowing of the bron- 
chus. 

Etiology: — It may be due to a constriction or 
a compression of a bronchus; of the former are 
cicatricial contractions the result of syphilitic ulcers 
within the bronchi, contractions of the bronchial 
sheath, malignant growths involving the caliber of 
the bronchus, or foreign bodies; of the latter are 
enlarged glands, aneurysms, tumors, abscesses, and 
pleural effusions pressing upon a bronchus. 

Pathology : — As the stenosis develops the secre- 
tions of that part of the bronchial tree are retained. 
At times the narrowed bronchus may yield and 
a discharge of the secretion takes place, after 
which it reaccumulates. In the majority of these 
cases the secretions distend the bronchi behind the 
stenosis. When the stenosis becomes more com- 



BRONCHIAL STENOSIS. 



plete there is ultimately a collapse of the lung. 
As a result of the retained secretions, secondary- 
changes of a destructive character ensue. 

Symptoms: — The symptoms present in a case 
are in proportion to the size of the bronchus in- 
volved, and the degree of the stenosis. There is a 
spasmodic cough which is accompanied by an ex- 
pectoration of a thick material. Dyspnea is pres- 
ent, and, like the cough, is paroxysmal in charac- 
ter and at times severe. As the pulmonary col- 
lapse develops there appears a dry pleurisy, and a 
localized dullness due to retraction of the lung. 
When the stenosis is the result of syphilis, there 
is a history of infection; when the result of an- 
eurysm, the symptoms are made worse by move- 
ment. 

Physical Signs: — Inspection. There is a de- 
fective respiratory movement on the affected side, 
which may show retraction during the later stages. 

Palpation: — This reveals a diminished or ab- 
sent tactile fremitus. 

Percussion: — This remains unchanged for a 
time and is not as much modified by forced in- 
spiration; as atelectasis takes place dullness is more 
pronounced. 

Auscultation: — The vesicular murmur is dimin- 
ished, and rales of various character are heard. 

Diagnosis: — In making a diagnosis the history 
of the patient and the condition of the thoracic 
organs preceding its development must be studied 
as well as the general symptoms and physical 
signs. This is one of the most difficult diseases 
to diagnose. 



82 BRONCHIAL STENOSIS. 

Prognosis : — It is generally a chronic, progres- 
sive difficulty, and the prognosis is unfavorable, es- 
pecially if it is a main bronchus that is involved. 
When due to a foreign body that can be removed, 
the prognosis is good. 

Treatment : — In the management of these cases 
the cause should always receive attention, as the 
controlling of it may relieve the case. Foreign 
bodies have been removed by emetics, but more 
frequently this is the work of the surgeon. The 
stenosis has been dilated with bougies. When 
syphilis is the cause it should receive the treatment 
demanded. In cases due to aneurysm, nitro-glycer- 
ine will often relieve the tension of the aneurysm 
and give a temporary relief at least. In some cases 
rest is beneficial. The iodide of sodium taken in- 
ternally has benefited a few. The ordinary cough 
medicines are of no benefit; chloral will be of more 
service than any of the anodynes in influencing the 
spasm of the bronchus. 



CHAPTER X. 
BRONCHIECTASIS. 



Definition: — This is a dilatation of the bronchial 
tube, due to an increased pressure within it, or a 
weakness of its walls. 

Etiology: — Bronchiectasis is secondary to dis- 
eases involving the bronchial tubes, which tend 
to weaken their walls or lessen their elasticity, as 
broncho-pneumonia, chronic pleurisy, tuberculosis, 
emphysema, and any condition that results in com- 
pression of the bronchus. Measles and whooping- 
cough produce this condition in children. A diseased 
condition of the mucous lining of the bronchial tube 
and deeper structures, by weakening the bronchial 
wall, favors its development. It is most frequently 
seen during adult life, and in males more frequently 
than in females. It is congenital in some cases. 

Pathology : — The dilatation may be either sac- 
cular or cylindrical; both forms are met with in the 
same lung. The saccular variety may involve a 
large part of a lung, or a bronchial tube during its 
whole length may be the seat of numerous sacculi. 
The cylindrical form most frequently involves the 
larger tubes. Both lungs are usually affected, the 
base of the lung showing , the first changes. The 
muscular structures are atrophied, the glandular 
tissue and the cartilages are involved in the pro- 
cess to such an extent that in the saccular varieties 
at least there is but a thin membrane lining the 
cavity. At the most dependent part of the dilata- 
tion an ulcer may be seen. 



84 BRONCHIECTASIS. 



Symptoms : — There is a paroxysmal cough 
which is worse at night and in the morning. It 
is attended with an expectoration of large quanti- 
ties of purulent and offensive secretions, which re- 
lieves the cough. The amount expectorated may 
vary from one ounce to two pints in twenty-four 
hours. The sputum is usually of a grayish brown 
color, and either of a sour or very fetid odor. 
When allowed to stand in a vessel it separates into 
three la3^ers; an upper one of brownish froth; a 
middle of a thin, sero-mucous fluid; and the lower 
of thick sediment. Under the microscope the 
sputum is seen to contain pus corpuscles, bacteria, 
and, if ulceration is present, elastic fibres. There 
is more or less dyspnea with some pain and hem- 
opt3'^sis; at times as ulceration takes place, fever, 
night sweats, diarrhea, and emaciation. 

Physical Signs: — Inspection. If the disease has 
advanced for some time there is more or less 
emaciation, the intercostal spaces are depressed, the 
chest wall is fixed, and the respiratory movements 
limited. There is a cough with an expectoration 
of a profuse, purulent, fetid material, which is more 
profuse when the body is in a position that favors 
its expulsion. 

Palpation: — This varies and is greatly dependent 
upon the amount of fluid in the cavities. Should 
the cavity be large, freely communicating with a 
bronchus, the vocal fremitus is increased. 

Percussion: — This reveals dullness, most marked 
over the middle and lower lobes which is removed 
after a free expectoration, when a vesicular, tym- 
panitic or amphoric resonance takes its place. 

Auscultation: — The respiratory murmur is often 



BRONXHIECTASIS. 



absent over cavities; while after a free expectora- 
tion there is a broncho-cavernous respiration at 
these points; rales either dry or moist, as vrell as 
gurgles, are to be heard at times. 

Complications : — On account of the ulceration 
that takes place in these cavities hemorrhages are 
liable to develop; in other cases the infection passes 
to the pulmonary structure and abscesses occur. 
As the result of the primary disease, a compensat- 
ing emphysema is established, which in turn leads 
to a dilatation of the right heart; and in time to 
congestion of the liver and kidneys. Induration and 
even hypertrophic changes may take place about 
the bronchi. Of the rarer complications are amy- 
loid change in the liver and kidney, gangrene of 
the lungs, and matastatic abscesses. Osteo-arthro- 
pathy is frequently noticed in connection with bron- 
chiectasis. 

Diagnosis : — In some cases the diagnosis is easy; 
in others the history of the case, the presence of a 
condition that has kept up a continual cough and 
the physical signs must all be taken into considera- 
tion. In children, a chronic cough with signs of 
emphysema following whooping-cough or pneumonia 
suggests bronchiectasis. In doubtful cases the X-rays 
will be found of assistance. 

It will be necessary to differentiate some of 
these cases from tubercular cavities, and pulmonary 
gangrene. 

TUBERCULAR CAVITIES. BRONCHIECTIC CAVITIES. 

1. Usually at the apex first. i. At the base first. 

2. The sputum is blood- 2. The sputum is foul, fetid, 
streaked, and contains tuber- but there are no tubercle 
cle bacilli. bacilli. 



86 BRONCHIECTASIS. 



3. Great and continued ema- 3. Emaciation not so rapid, 
ciation. 

PULMONARY GANGRENE. BRONCHIECTASIS. 

1. It is secondary to pneu- i. Secondary to chronic bron- 
monia. chitis usually. 

2. Systemic symptoms develop 2. Symptoms develop slowly, 
rapidly. 

3. Sputum contains shreds of 3. It does not. 
pulmonary tissue. 

4. There are grave constitu- 4. Are not so grave, 
tional symptoms. 

Prognosis : — In children there may be an irri: 
provement; in adults these cases are incurable, but 
the patient may live for many years. 

Treatment : — In the management of these cases 
the nutrition of the patients must be maintained. 
Expectoration should be rendered easy and the fetor 
corrected so far as is possible. They should, if 
possible, Hve in a dry climate where the variation 
of the temperature is slight. If this is found im- 
practicable, their clothing should be woolen, and 
such as will protect them from sudden changes of 
temperature, and their occupation of such a charac- 
ter as to not expose them to severe storms, or 
other influences that will produce a fresh catarrh 
of the air passages. 

The diet must be nutritious and abundant; and 
all the oil and fats the patient can digest should be 
administered. Those who are lean will derive ben- 
efit from inunctions of oil during the winter. For 
this purpose olive, cocoanut, or cotton-seed oil 
will be found most serviceable. 

Certain remedies have been used by inhalation 
in the form of vapor. There are many instruments 



BRONCHIECTASIS. 87 

upon the market for giving these inhalations; but 
when any one of them is not at hand the medicine 
to be used may be dissolved in alcohol, then diluted 
in ether or chloroform, and inhaled from a sponge; 
or it may be mixed with albolene or other purified 
petroleum oil and inhaled from a steam or hand 
atomizer. This latter form of inhalation, while it 
is of some service, is disappointing, and does not 
produce the desired results. The medicine may be 
mixed with water if not resinous in character. 
The use of creosote vapor baths has been at- 
tended with better results. In order to employ 
this, a small room should be cleaned, all the furni- 
ture removed except a wooden chair and such articles 
as will not be injured. The patient's eyes must be 
protected by masks, or goggles that will not allow 
the fumes to get to the eyes. His clothing 
should also be protected, as well as the hair of the 
female; the nostrils should be closed with plugs of 
cotton. When all is ready the creosote should be 
heated, which causes dense clouds of vapor to fill 
the room, and produces violent coughing and ex- 
pectoration on the part of the patient; at times 
vomiting follows the coughing. At first these baths 
may be given every other day, the . duration being 
from fifteen to twenty minutes; after a short time 
the patient is usually able to take the bath every 
day, and the duration of each is to be increased 
gradually to an hour and even longer. By follow- 
ing this method of treatment the fetor and ex- 
pectoration disappears in many cases, and yet there 
are some cases that show but little improvement. 
This treatment should be followed up faithfully for 
three or four months. 



88 BRONCHIECTASIS. 



Another method is the intra-tracheal injection of 
one drachm of a preparation consisting of menthol 
ID parts, guaiacol 2 parts, olive oil 88 parts. In 
using this, care must be taken that the point of the 
syringe has passed into the trachea, or is at least 
below the larj/nx. It should be used twice daily. 

There is a tendency to employ sedatives in this 
class of cases but they are injurious. These patients 
should be instructed to ''cough down hill" — that is, 
the head and shoulders should be much lower than 
the remainder of the body. It will be necessary to 
rotate the body that each cavity may be thoroughly 
emptied. Of all the remedies at our disposal 
none will obliterate these cavities, and the result 
will only be partially satisfactory. 

For the indications of the following remedies, 
see the therapeutics of chronic bronchitis: sulphur, 
stannum iodatum, hepar sulphur, silicea, calcarea 
carbonica, copaiva, saw palmetto, eucalyptus and 
balsam of peru. 



1 



ATELECTASIS. 

Definition: — This is a condition of the lung in 
which the whole or a part of it is airless. The 
term is applied to two different conditions; in the 
one (atelectasis proper), the alveoli have never 
been distended with air, the area being dense, 
bluish, brownish red, like a fetal lung; while in the 
other (collapse of the lung), the alveoli are col- 
lapsed; either one here and there, or a section of 
the lung. 



ATELECTASIS. 89 

Etiology: — Atelectasis proper occurs as a result 
of obstruction of the bronchi due to mucus or me- 
conium. In weakly children and those prematurely 
born, the lung ma}^ not fill throughout. Collapse 
of the lung is observed most frequently in connec- 
tion with bronchitis in those with feeble respiratory 
power. Any condition that produces great weak- 
ness always favors its development. 

Pathology : — In the congenital form it is the 
base and the posterior portion of the lungs that are 
most frequently affected. The area involved is of 
a dark reddish color; sinks in water and does not 
crepitate under pressure. At times there is but a 
small portion of the lung involved; but more fre- 
quently there is a considerable area. When death 
does not result there are secondary changes in the 
lung; the pleura over the part becomes thickened, 
there is a proliferation of the connective tissue of 
the septa, and a degeneration of the epithelial cells 
of the alveoli. When these changes have developed 
the atelectasis is permanent. In collapse of the lung 
the part is dark in color, reduced in size and the 
pleural surface is depressed. Secondary changes re- 
sult here as in the congenital form, and the collapse 
becomes permanent. 

Symptoms : — In the new born, complete atelec- 
tasis is incompatible with life. When it is but par- 
tial it is indicated by feebleness, dyspnea, rapid, 
shallow respirations, a varying degree of cyanosis, 
with drowsiness, twitching and convulsions. The 
temperature is below normal; the cry is feeble, and 
there is general weakness. It will be noticed that 
the intercostal spaces in the inframammary and lat 
eral regions, retract during inspiration; and should 



90 ATELECTASIS. 



life be prolonged the sternum becomes prominent 
and the thorax deformed. The duration of the 
child's life is in direct proportion to the cyanosis 
present, varying from a few days to months, and 
even longer. 

Physical Signs : — Inspection. The subject, 
whether an infant or adult, is .weak, emaciated, and 
sickly in appearance, the skin being either pale or 
dusky. The respirations are very rapid, the pause 
following instead of preceding inspiration. The 
lower ribs and intercostal spaces are retracted dur- 
ing inspiration. 

Palpation: — The pulse is feeble and rapid, and 
the extremities are cold, while vocal fremitus is ex- 
aggerated over the base of the lungs. 

Percussion: — When the area is large, the dull- 
ness is marked; when small it is not so easily re- 
cognized; this is especiall}^ true in children. 

Auscultation: — The vesicular murmur is dimin- 
ished over the area of collapsed lung; the breath- 
ing is broncho-vesicular, and rales are numerous. 

Diagnosis: — This is often difficult. The col- 
lapsed area is airless and as a result is dull on per- 
cussion, while the respiratory murmur is faint, or 
absent. Should edema be present moist crepitant 
rales are heard. 

Prognosis: — The degree of cyanosis present is 
always a criterion by which to form a prognosis; 
should the cyanosis be progressive and gradually be- 
come more pronounced the outlook is unfavorable; 
should it gradually become less marked the prog- 
nosis is more favorable. Should the atelectasis 
appear as a complication of some of the acute dis- 



ATELECTASIS. pi 

eases, it is alwa^^s grave, and more so if the child 
is suffering from rickets. 

In all cases the amount of cyanosis, dyspnea, and 
the strength of the patient should be taken into 
account. If recovery takes place the patient may 
be subject to bronchiectasis or tuberculosis, and 
should the collapsed portion be reflated, the de- 
formity, present during the early stages, may be- 
come permanent. 

Treatment : — Attention should be devoted to the 
new-born so that respiration is satisfactorily estab- 
lished. It may be excited by placing the infant in 
a bath of hot water (ioo°F.) and massaging thor- 
oughly. At times the sprinkling of cold water upon 
the chest will be found sufficient. It should be 
ascertained that nothing is obstructing the air pas- 
sages and that all mucus is removed. When the 
child is removed from the bath it should be wrapped 
in warm cotton batting. The lungs ma}^ be inflated 
by clearing the face "and mouth of mucus, closing 
the nose and blowing into the mouth. 

Those who are weak should guard against pul- 
monary troubles in order that atelectasis may be 
avoided. When collapse is secondary to paralysis 
of the diaphragm, artificial respiration is of service; 
while in those cases where it is secondary to pleu- 
risy, gymnastic exercises are beneficial. A resi- 
dence at a high altitude is also of service as it 
demands deep breathing. In those cases that appear 
as the result of various lung diseases, remedies may 
be called for, but they are of no service in the 
congenital form. Deep inspirations and a change 
of position from time to time should be practiced 
in these cases. Inhalations of oxygen and a few 
doses of strychnia are beneficial. 



CHAPTER XL 
VESICULAR EMPHYSEMA. 



Definition: — This is an excessive and permanent 
dilatation of the alveoli and air sacs of the lungs. 

Etiology : — It is more common among men than 
women; and in those past the meridian of life. A 
hereditary tendency to it is observed in certain 
families, where it is the result of defective develop- 
ment of the elastic tissue of the lung. It is found 
where there is an increased air pressure within the 
lung resulting from nasal obstructions in children, 
or such occupations in the the aged as demand 
continuous and severe muscular effort, as black- 
smithing, or playing upon wind instruments. The 
diseases that give rise to coughing, as chronic 
bronchitis and whooping cough; mitral diseases and 
the lessened elasticity of the lung tissue of advanc- 
ing age, also act as causes. 

Pathology :—T\vQ establishing of a condition of 
emphysema in the lung is a slow process. The 
first changes are in the infundibula and alveoli, 
which are dilated as a result of the increased ex- 
piratory effort, the elastic tissue not being able to 
withstand the increased pressure. As the alveolar 
walls stretch they become thin, and the capillaries 
disappear from them. This thinning continues until 
the walls between the alveoli rupture, and cavities 
the size of a hen's ^gg may be formed. The es- 
tablishing of this process leads to a diminution of 
the aerating surface of the lung; and the obliterat- 



VESICULAR EMPHYSEMA. 93 

ing of the capillaries leads to an increased tension 
in the pulmonar}^ artery, and to hypertrophy of the 
right side of the heart. A collateral circulation 
takes place through the bronchial arteries but it is 
slight. As the elastic tissue disappears from the 
alveolar walls, expiration becomes more labored and 
prolonged, and a position of continual inspiration is 
assumed by the patient. Early in the establishment 
of the process there is a derangement of the cir- 
culation, cyanosis appears, the veins are seen to be 
distended, and a relative tricuspid insufficiency, due 
to dilatation of the right ventricle, is observed. 
The circumference of the chest is increased, the 
arch of the diaphragm is lowered, the lungs are 
pale and are seen to overlap when the sternum is 
removed, while the area of superficial cardiac dull- 
ness is diminished or obliterated; as the elastic 
tissue is destro3'ed the lungs lose the power of 
retracting, and, as a result, they appear voluminous. 
When squeezed they collapse, do not crepitate, are 
not elastic, and show large alveolar spaces under 
the pleura. 

Symptoms : — Vesicular emphysema develops 
slowly, its symptoms being gradually added to 
those of the primary complaint. In the compensa- 
tory form, and during such diseases as whooping 
cough, they may develop rapidly but in the ordi- 
nary type of the disease the first symptom com- 
plained of is dyspnea, which is expiratory in char- 
acter, and only observed, at first, when some task 
is undertaken that is out of the usual, as going up 
stairs, and running or walking rapidly soon after a 
full meal. At first this dyspnea is paroxysmal, 
while later it becomes continuous, and is aggravated 



94 VESICULAR EMPHYSEMA. 

by the slightest exertion, so that speaking is inter- 
fered with, the sentences becoming fragmentary. 
Inspiration is shortened, while expiration is pro- 
longed, and when chronic bronchitis is present it is 
accompanied by wheezing. Later, when the pul- 
monary circulation is interfered with and compen- 
sation is failing, cyanosis appears; while later still, 
as the dyspnea increases, the blueness is more pro- 
nounced. Cough is present in all those cases where 
chronic bronchitis is the cause, and is accompanied 
with an expectoration that is similar to that found 
in chronic bronchitis. There is a gradual loss of 
flesh and strength, the patient presenting a cachectic 
appearance. The pulse is feeble, but may be nor- 
mal in time, while the temperature is often sub- 
normal. 

Physical Signs: — Inspection. This reveals a 
chest that is barrel-shaped. The posture is stoop- 
ing, the sterno-cleidomastoids are prominent; the 
shoulders are elevated, which makes the neck appear 
shortened. The chest presents a broad, deep, 
rounded-out appearance with an increased antero- 
posterior diameter. The intercostal spaces in the 
upper part of the chest are wider than normal, 
while the scapulse are widely separated. There is 
but little movement of the chest, the breathing 
being chiefly diaphragmatic, while the false ribs 
and the lower intercostal space retract during in- 
spiration. 

Palpation: — Vocal fremitus and resonance are 
nearly alwa3^s diminished; in some cases they are 
normal or increased. The apex beat of the heart 
is rarely palpable. 

Percussion: — Hyper-resonance is present, the per- 



VESICULAR EMPHYSEMA. 95 

cussion note being clear and at times tympanitic, 
though if the distension is pronounced the note may 
be woody. The area of pulmonary resonance is 
extended in all directions. Dullness over the heart, 
liver and spleen is lessened, and their area of flat- 
ness is narrowed. 

Auscultation: — This reveals an inspiration that 
is distinct but feeble and shorter than usual, while 
expiration is prolonged and low pitched. Various 
adventitious sounds may be heard, due to the asso- 
ciated bronchitis, pleurisy, or tuberculosis. The 
heart suffers with the lungs. The apex beat is 
absent, and the whole area of cardiac dullness may 
be obliterated by the distended lung. The apex 
beat may be observed at the xiphoid cartilage at 
times; while there is usually a distinct epigastric 
pulsation the result of the dilatation and hypertro- 
phy of the right ventricle. The second pulmonary 
sound is accentuated, while a murmur of relative 
tricuspid insufficiency may be heard. Toward the 
latter stages venous congestion is common, albumen 
appears in the urine, and while edema of the feet 
and legs may appear, general anasarca is not the 
rule. 

Complications and sequelce: — While bronchitis is 
recognized as one of the causes of emphysema, the 
presence of cmph3^sema aggravates it. The circu- 
lation of the blood is interfered with to a greater 
or less extent, leading to an increased tension in 
the pulmonary artery, and ultimately to a hyper- 
trophy, and later a dilatation of the right ventricle 
of the heart. The heart is displaced downward. 
The liver is congested and enlarged, while the 
hepatic veins are dilated. The kidneys are enlarged, 



96 



VESICULAR EMPHYSEMA. 



cyanotic, and granular, the result of chronic inter- 
stitial nephritis, which is frequently associated with 
emphysema. The spleen is enlarged, while the 
stomach is usually in a catarrhal condition. 

Diagnosis-' — In making a diagnosis the history 
of the case must be taken into consideration; the 
length of duration, the occupation, and at times 
heredity, with the presence of dyspnea, cyanosis, and 
a cough with indications of chronic bronchitis, together 
with the physical signs all contribute to this end. 



EMPHYSEMA. 

1. Results from long continued 
expiratory effort with the 
glottis closed. 

2. The onset is slow. 

3. Location bilateral. 

4. Auscultation, breath sounds 
are feeble, expiration pro- 
longed and low pitched. 
Vocal fremitus and reson- 
ance are diminished. 



EMPHYSEMA. 

1. This results from causes as 
stated in the etiology. 

2. Percussion note almost tym- 
panitic. 

3. Extent rarely unilateral. 



4. Breath sounds are every- 
where feeble. 



PNEUMOTHORAX. 

1. From a break in the pleura 
establishing a communica- 
tion between the pleural 
cavity and bronchi. 

2. Sudden. 

3. Unilateral. 

4. On inspiration an am- 
phoric blowing sound is 
heard. Egophony succus- 
sion sounds, or metalic tink- 
ling are heard if pleurisy, 
with effusion, has taken 
place. 

PLEURAL EFFUSION. 

1. Results from pleurisy, dis- 
ease of the heart or kidneys. 

2. Hyper-resonant above the 
fluid but flat over the fluid. 

3. Usually unilateral except 
when the result of a general 
dropsy, when it is bilateral. 

4. They are not well heard 
through the effusion but are 
puerile or bronchial above 
the effusion. 



VESICULAR EMPHYSEMA. 97 

5. Vocal resonance and frem- 5. Absent below the level of 
itus diminished. the effusion. 

6. Purulent termination does 6. Indicated by rigors, hectic 
not take place. fevers, sweats, and marked 

emaciation. 

Prognosis : — This must take into consideration 
the station in life, the complications and sequelae. 
If the subject is well-to-do, so that he need not be 
exposed to all forms of weather, and can remain 
indoors during the winter, or go to a milder climate 
for these months, the prognosis is not so grave; if, 
however, his position is such that he is exposed to 
all forms of weather the prognosis becomes more 
grave. In other cases it is the complications that 
kill, as rheumatic attacks, catarrhal or croupous 
pneumonia, or failure of the right side of the heart. 
In those cases where no intercurrent disease is pres- 
ent, a general dropsical condition with nutritive dis- 
turbance appears, associated with chronic passive 
congestion of the various organs. 

Treatment : — This is an incurable disease, as the 
degenerative changes are permanent; and the most 
that can be hoped for is to arrest or retard its 
progress and prevent the mild cases from becoming 
severe by controlling the causes that are oper- 
ative. Early in the history of the case the diet 
should be highly nutritious, while later, when the 
organs are weakening, it may be found necessary 
to resort to a milk diet. Starches and alcohol 
should be avoided so far as possible, while tobacco 
is an abomination to these patients. 

Exercise in the open air is to be encouraged 
but should not be carried to the point of fatigue. 
Inhalations of oxygen are beneficial, while an 



98 VESICULAR EMPHYSEMA. 

arrangement whereby the patient can inhale com- 
pressed air and exhale into a rarified air is de- 
sirable. In some cases the pneumatic cabinet will be 
of service. The patient who can should spend the 
winter in a warm climate, and wherever he is, 
bronchitis should be avoided, so far as possible; 
attention should be devoted to the bowels, that 
they do not become constipated, as straining at 
stool is harmful. As stated before, it is impossible 
to restore a destroyed portion of the lung, and any 
remedy that may be indicated will only stay the 
disease or relieve impending symptoms. 

Breathing exercises, to be of service, should be 
taken early. While in a state of ordinary inspira- 
tion the patient should expire through the open 
mouth, bending the body forward in order to com- 
press the lung between the flexed thorax, and the 
diaphragm; the abdominal muscles should also be 
exercised. This should be practiced for at least 
half an hour twice a day. 

Veratrum viride: — This remedy will give relief 
where there is marked dyspnea and lividity with 
great engorgement of the veins; a condition in 
which some would consider bleeding necessary to 
relieve the patient. One to three drops of the 
tincture every half hour for a few times, and then 
at lengthened intervals will be found serviceable. 
In very urgent cases it will be found to act quicker 
if given hypodermatically. 

Lobelia inflata: — This remedy often relieves the 
distress attending occasional smothering in the 
chest. There is a constant d3'spnea which is aggra- 
vated by the slightest exertion, and increased by a 
slight exposure to cold. 



VESICULAR EMPHYSEMA. 99 

Arsenicum iodatum: — In those cases where there 
are signs of senile degeneration, as indicated by the 
hardened arteries, the general senile condition of 
the patient, and the heart is suffering, this remedy, 
given in one grain doses of the 2x four times a 
day, has given excellent results. 

Tartarus emeticus: — When bronchitis is a prom- 
inent feature of the case; there appears to be large 
collections of mucus in the bronchi but nothing 
comes up. The face is cold, and covered with cold 
perspiration. 

Naphthalinum: — This remedy has been used in 
cases due to playing upon wind instruments. 

Antimoninm arsenicum: — This has proven ser- 
viceable in cases of emphysema where there is ex- 
cessive dyspnea, with a weak heart, and a cough. 

Erythroxylon coca: — This has been recommended 
in teaspoonful doses of the tincture. 

Aspidosperma quebracho: — This, in ten-drop 
doses of the tincture, has been employed with a 
degree of success; in some cases the one-fiftieth of 
grain of aspidospermine will be found to act well. 

When the heart shows enfeeblement, strychnia, 
sparteine, arsenic and at times digitalis will be of 
service. 

Any remedy that will assist in improving the 
general health of the patient will be of service; as 
calcarea carbonica, in fat women suffering from 
bronchitis, with profuse perspiration and menstrua- 
tion; phosphorus, where there is a tendency to fatty 
degeneration; lycopodium, when lithemic symptoms 
indicating this remedy are present; while in those 
cases where there is a high arterial tension, glon- 

oine or amyl nitrite may be called for. 
LofC. 



lOO VESICULAR EMPHYSEMA. 

The reader is also referred to the remedies 
mentioned under chronic bronchitis and asthma. 

Senile Emphysema: — This form is observed in 
those thin aged people who are undergoing a gen- 
eral senile atrophy; the changes in the lungs are 
not out of proportion to those found in other parts 
of the body. 

The chest is flattened; there is hyper-reson- 
ance, the respiratory murmur is faint; expiration 
is prolonged; but the condition does not give rise 
to the interference with the pulmonary artery that 
is met with in the hypertrophic form and as a 
result the heart does not suffer. There is a slight 
cough, with shortness of breath. The elastic tis 
sue of the lung is but little, if any, affected. 
The lungs are not voluminous, do not crepitate 
upon pressure, do not cover the heart, but are 
pale. In managing such a case there is but little 
to do apart from general treatment for senile de- 
generation. 

Compensatory Emphysema: — This is a term ap- 
plied to an over-distension of the alveolar walls, 
and enlargement of the alveolar spaces, usually 
without structural changes. It is found in lungs 
where there is some pathological process already 
present that renders a part of the lung useless, 
and a greater pressure is, as a result, thrown upon 
the healthy portion. This form of emphysema is 
either transient or permanent, according as the 
cause is permanent or recovered from. It is found 
with pleurisy, pneumonia and atelectasis. 



VESICULAR EMPHYSEMA. lOI 

INTERSTITIAL OR INTERLOBULAR EMPHYSEMA. 

Definitio7i: — This is a term applied to an escape 
of air into the connective tissue of the lung. 

Etiology : — It may be due to perforating wounds 
of the chest wall, fractured ribs, or prolonged par- 
oxysms of coughing where there is some obstruc- 
tion to expiration. At times there is an inflam- 
matory or degenerative weakness that predisposes 
to this lesion. It is frequently observed as a 
result of whooping cough, membranous croup, def- 
ecation, parturition, and various forms of convul- 
sions; also from blowing upon wind instruments. 

Pathology : — The air from the ruptured alveoli 
finds its way to the interlobular and subplural con- 
nective tissue, where it forms small blebs that may 
be moved from place to place; they may extend 
to the root of the lung, or to the mediastinal tis- 
sue of the neck. The pulmonary pleura may be- 
come detached and an air tumor the size of a 
marble, or larger, may form. These air sacs may 
rupture and a pneumothorax result. 

Symptoms: — It may not be recognized during 
life. When pneumothorax appears the dyspnea 
becomes severe. 

Treatment: — There is no definite treatment. 
Undoubtedly this condition is present in many 
cases, though it is unsuspected, the air being ab- 
sorbed. It develops rapidly, and is frequently 
followed by emphysema of the neck, which, upon 
palpation, gives a peculiar crepitation. 



I02 VESICULAR EMPHYSEMA. 

BRONCHIAL CONCRETIONS. 

Synonym: — Lung stones. These may be found 
in the bronchial tubes, the bronchial glands, or in 
the parenchyma of the lung. Some of them are 
as large as hazel nuts; and they may be round 
or irregular. They may be white or yellow in 
color, and are composed principally of the car- 
bonate and phosphate of lime. Their origin is not 
known but has been attributed to inhalation of 
dust; the healing of tubercles where nature has 
poured out an excess of lime salts; or the degen- 
eration of tubercles. 

In some cases there are no symptoms, while in 
others there are all the evidences of some pul- 
monary lesion, such as elevation of the tempera- 
ture, rapid pulse, rales, with expectoration of a 
purulent or bloody material, and, at times, hectic 
symptoms. 

The physical signs may point to the presence 
of a cavity. 

There are no specific signs upon which to base 
the diagnosis. This can only be positive when 
the concretion is brought us. 

They may remain for a long time without giv- 
ing rise to any difficulty, but when once disturbed 
may then act as an irritant and cause a more 
general infection. 

As it is impossible to diagnose these cases, the 
treatment must be along general lines. 

Bronchial Flukes: — A parasitic affection. Epi- 
demics appear in Japan, China and Formosa in 
which these are present accompanied by cough and 
hemoptysis. 



CHAPTER XII. 
ASTHMA* 



Definition: — This is a chronic neurotic affec- 
tion characterized by paroxysmal attacks of dys- 
pnea. 

Varieties: — The following forms are mentioned: 
Spasmodic asthma in which the nervous 

element predominates. 
Bronchial asthma occurs in those suffering 

from bronchitis. 
Cardiac asthma occurs in those with cardiac 

disease. 
Renal asthma occurs in those suffering with 

renal diseases. 
Hay asthma results from the pollen of cer- 
tain plants or flowers. 
Etiology: — It is frequently a difficult matter to 
arrive at the cause in a given case. Heredity 
appears to be an important element, for in 50 per 
cent, of these cases there is a family history of 
an unstable nervous organism. Though it may 
appear at any age, a large percentage of cases show 
indications of the disease before the patient is ten 
years old. Men are more frequently affected than 
women in the proportion of at least two to one. 
Apart from hay asthma it occurs most frequently 
during the winter and early spring. 

Some cases are of a central nervous origin, 
since emotions at times excite an attack. Neuras- 
thenia is also recognized as a probable cause. 



I04 ASTHMA. 



Among the peripheral causes are those of a nasal 
origin, due at times to nasal polypus, in other 
cases to vascular turgescence of the cavernous 
tissue covering the turbinated bones; or to a 
chronic thickening of the nasal mucous membrane. 
There are certain individuals v^^ho are seized with 
an attack whenever they inhale certain odors or 
gases; as that from sulphuric acid, chlorine, and 
the odor of certain animals. A common cause is 
an inflammation of the bronchial mucous membrane, 
which is modified, to an extent, by the locality 
and climate. In other cases fog, the irritation due 
to dust; the electric condition of the locality, and 
gastro-intestinal disturbances are the causes. 

Peptic asthma results from constipation, flatu- 
lence, and indigestion of some particular food. 
Cold applications to the surface of the body; 
especially cold feet and uterine irritation have 
been recognized as the cause of a few cases. 
Those having a uric acid diathesis who suffer from 
gout are apt to alternate this disease with asthma. 
The patient is frequently from the higher walks of 
life and is subject to hemicrania, epilepsy, or 
neuroses. 

Pathology: — Asthma presents no characteristic 
lesion, and there is no theory regarding its path- 
ology that is generally accepted. By some it is 
considered a bronchial spasm, by others a spasm 
of the diaphragm, while a third class looks upon 
it as a hyperemic condition of the mucous mem- 
brane of the bronchial tubes. The amount of the 
expectoration varies; toward the end of the par- 
oxysm it becomes more or less free and consists 
of semi-transparent, grayish, mucous pellets — the 



[ 



ASTHMA. 105 



''boiled tapioca" expectoration. In it are spiral 
corkscrew threads of mucin and pointed octahedral 
crystals of phosphoric acid with an organic base. 
In old, long standing cases there is a developed 
emphysema of the lungs, dilatation of- the right 
ventricle of the heart, and a chronic catarrhal 
bronchitis. Renal and cardiac asthma are but 
symptoms of a disease of these organs and should 
not be considered as real asthma. 

Symptoms: — In some cases there appears an 
''asthmatic aura" which the patient recognizes as 
the sign of an approaching attack. This may be 
in the form of buoyancy, headache, drowsiness, 
gastric disturbance, coryza, wheezing cough, or 
the passage of a large quantity of pale limpid 
urine. 

The onset of an attack is usually gradual but 
at times it is rapid. There is a slight tightness 
across the chest, which becomes gradually worse. 
In some cases it begins during sleep. The dys- 
pnea becomes rapidly more severe, until it is 
extreme, when the face is pale and anxious, is 
covered with a cold perspiration, and the lips are 
dusky, due to a lack of oxygenation of the blood. 

There is a sensation of smothering, the patient 
often goes to an open window or sits up in bed 
and supports the body on the hands to assist the 
accessory muscles of respiration. After all his 
efforts the thorax moves but little, as the lungs 
are distended and on account of the bronchial 
spasm he is unable to expel the contained air. 

The attack may last from half an hour to a 
day or two, though if chronic bronchitis is present 
the duration may be from one to two weeks, there 



I06 ASTHMA. 



being slight remissions during the day. As the 
attack subsides, the expectoration becomes profuse, 
and consists at first of round gelatinous masses, 
which, if they are unfolded under water, will be 
found to be made of spirals. Later the expector- 
ation becomes muco-purulent in character. 

Physical Signs: — Inspection. The patient is 
found either standing or sitting with the elbows 
resting upon some support. The face presents an 
expression of distress and anxiety. There is more 
or less perspiration. The mouth is open; the 
nostrils dilated; the face and neck cyanosed; and 
the sterno-cleido mastoids are prominent. In cases 
of long duration the chest is barrel-shaped. The 
respirations are usually increased in frequency. 
Inspiration is short and quick, while expiration is 
prolonged and dyspneic. The movements of the 
chest are lessened, and the diaphragm lowered. 

Palpation: — This does not give much informa- 
tion apart from showing the pulse to be small, 
feeble, and rapid; and the skin to be cold and 
clammy. 

Percussion: — This will show hyper-resonance, 
especially if emphysema has developed. 

Auscultation: — Respiration is harsh; inspiration 
is faint and short; while expiration is prolonged. 
Both sibilant and sonorous rales are heard, which 
are most marked on expiration. 

Diagnosis: — This is usually rendered easy by 
a careful study of the symptoms, the physical 
signs and microscopical examination of the sputum. 

Differential diagnosis: — In laryngeal and 
tracheal stenosis the dyspnea is expiratory and 



ASTHMA. 107 



attended with a decrease in the size of the chest 
and an elevation of the diaphragm. 

In cardiac asthma the expiration is not pro- 
longed, while the breathing is rapid, panting and 
sighing. 

Dyspnea due to aneurysm is attended with a 
localized dullness and pulsation, a brassy cough, 
and at times tracheal tugging, with local paralysis, 
and diminished vesicular murmur in the upper lobe 
of the left lung. 

In paralysis of the diaphragm the dyspnea is 
continuous, and inspiration is attended with an 
expansion of the chest and depression of the 
abdominal walls, while in expiration the chest 
collapses and the abdominal wall is elevated; 
attempts to bear down are ineffective. 

Whooping-cough has been mistaken for asthma, 
but it is a disease of childhood. There is the 
characteristic whoop, while the duration of the 
disease is not more than two months. 

Prognosis : — This is estimated by the amount 
of damage done to the lungs and heart by the 
emphysema of the former, and the dilatation of 
the right ventricle of the latter. Though the per- 
centage of cases that are completely cured is 
small, it is not a disease that kills, nor is there 
a probability of the development of intercurrent 
diseases such as tuberculosis and cancer. The 
secondary changes are in proportion to the sever- 
ity and frequency of the attacks. 

Treat7nent : — The successful management of a 
case of asthma demands a most thorough and 
minute investigation of every phase of the patient's 
life, and of his physical condition. It is always 



I08 ASTHMA. 



advisable to get all the information possible from 
the patient regarding his case as in the majority 
of cases he has observed its every peculiarity. 
The task of the physician is not confined to cut- 
ting short the paroxysms, but embraces such a 
management of the case that these may be averted 
altogether, before that habit which the system is 
developing has become fixed. 

The removal of the patient from the surround 
ings that have assisted in developing the disease 
is desirable. If it has been the dust and impure 
air of a city, often a locality with pure air will be 
beneficial. The same is true of the home in which 
the individual has lived; if it is cold and damp, 
then one that is dry and warm is to be sought 
out. There are idiosyncrasies in each case that 
render it hard to say just what climate will be of 
most benefit. Some cases may be obliged to 
migrate as the different seasons approach. A sea 
voyage frequently brings great relief to those 
whose first attack was due to break of the nervous 
sj'stem from anxiety, excesses or overwork. 

The secondary changes in the lungs and heart 
should be considered before making any change. 
Certain cases will be found to improve by removal 
to a city, especially those who have resided in 
damp localities. A moderate elevation with a dry 
climate in the pine or fir regions is to be pre- 
ferred, as is found in Minnesota, Idaho, Wyoming, 
Wisconsin, Michigan, and parts of New York. 
The patient may have to travel from point to 
point until one is found that gives relief to his 
particular case. 

Careful attention should be devoted to the ex- 



ASTHMA. 109 



citing cause, that it may be removed; this will 
demand much patience on the part of both the 
physician and patient, as many of the latter think 
merely of relief from the attack. When a catarrhal 
condition of the bronchial mucous membrane is the 
exciting cause such measures must be adopted as 
will protect the sufferer from recurrent attacks. 

Diet: — These patients should take the principal 
meal at midday, as retiring at night before diges- 
tion is completed, is a frequent cause of an attack. 
The attacks of peptic asthma are usually dependent 
upon undigested food rather than upon the ingestion 
of any particular food. These patients should avoid 
alcohol, while coffee nearly always precipitates an 
attack if taken after dinner. 

For individuals who are exhausted a rest that 
will restore the vitality will be found service- 
able in many cases; while in those cases where 
uric acid is the exciting cause the diet must be 
regulated, and proper exercise instituted. Deep, 
systematic breathing is frequently of service in 
these cases. 

During the acute attack one of the following 
remedies may prove serviceable. 

Apomorphinum muriaticum: — In cases where 
there is not much secretion of mucus in the bron- 
chial tubes this drug in doses of one-tenth of a 
grain, either by mouth or hypodermically, is often 
of service. 

Lobelia inflata: — This is a standard remedy 
with many during the paroxysm, but it should be 
given with great care to those who are delicate 
and have weak hearts. It is a most powerful 
emetic. Ten drops of the tincture in a teaspoon- 



no ASTHMA. 



ful of chloroform water every twenty or thirty min- 
utes should be given until the patient is relieved. 

Amyl nitrosum (nitrite): — In those cases where 
there is coldness of the hands and feet, with cold 
perspiration, weak heart action, and spasmodic 
constriction, five or six drops upon a handkerchief, 
taken by inhalation will bring relief. When a 
more lasting result is desired than that given by 
amyl nitrite, either glonoine or one to two grain 
doses of nitrite of soda may be given. Ether and 
chloroform have each been used by inhalation 
with benefit in some cases, but such a habit is to 
be avoided. 

Coffee: — A pint of strong coffee taken without 
sugar or cream is used by some asthmatics. 

Kali nitricum: — Inhalation of the fumes caused 
by the burning of a piece of brown or blotting 
paper that has been soaked in a solution of nitrate 
of potash and then dried, will relieve many cases. 
The atmosphere of the room must be saturated 
with the fumes. This paper may be made into 
cigarettes and smoked. A decoction of stra- 
monium mixed with the nitrate enhances its value 
as an anti-asthmatic. 

Chloralum hydratum: — In from two to twenty 
grain doses is often of service but it should be 
used with caution in those with weak hearts. 

Opium: — This drug, in the form of paregoric, 
( tinct. opii camph. ), maybe used in emergency for 
women and children. 

Morphinum sulphuricum: — This is used by 
many as a palliative and often gives relief, but is 
not to be recommended. When used, one-eighth 
to one-fourth of a grain may be combined with 



ASTHMA. Ill 



atropine or cocaine, with benefit. When it is com- 
bined with cocaine, one-eighth of a grain of mor- 
phia and one-fourth of a grain of cocaine may be 
used. It should not be employed in the bronchial 
asthma of the aged or where there are indications 
of profuse bronchial catarrh. Under no circum- 
stances should morphia or opiates in any form be 
used to control cases of renal or uremic asthma. 
Chloroform or the nitrite of amyl is to be pre- 
ferred in such cases. It should be administered 
by the physician only, and should not be left in 
the hands of the patient or his friends. 

When the patient feels that he must have 
something to apply to the chest, a liniment, con- 
sisting of turpentine and iodine is of service. In 
cases where emphysema is present in a marked 
degree, a compressed air bath may be of benefit; 
should the bath be followed by an attack of severe 
dyspnea it is best to avoid its further use, as a 
prolonged attack may follow the second bath. 

Arsenicum album: — This remedy is probably 
the most serviceable one we have in the treatment 
of asthma. The attacks have a period of aggra- 
vation after midnight, there is great exhaustion 
with anguish, restlessness, and fear of death. 
There is constriction of the chest as though the 
patient would suffocate, which is aggravated while 
lying down. In certain cases some of the follow- 
ing combinations of this remedy will be found of 
value. 

Antimonium arsenicicum (2x): — When there is 
pulmonary congestion with weak heart action. 

Strychninum arsenicicum (2x): — When the mus- 



112 ASTHMA. 



cular tone is low, especially the respiratory mus- 
cles. 

Cuprum arsenicosum: — When with the arseni- 
cum symptoms there are the cramping pains that 
demand cuprum. 

Aurum arsenicosum (3X): — In cases of children 
where there is more or less laryngismus stridulus. 

Kali iodatum: — This remedy is to be studied in 
those cases where there are secondary or tertiary 
effects of syphilis; scrofula; rheumatism; or where 
the system has been saturated with mercury. The 
mucous membrane is chronically inflamed, giving 
rise to coryza, with watery nasal discharge, and 
accompanied by constant sneezing. There is great 
oppression of breathing with constriction of the 
chest, which is so pronounced that the patient 
declares he will die. There is a chronic discharge 
from the bronchial mucous membrane of a large 
amount of green material, which looks and smells 
as if it were the result of an actual degeneration 
of the tissues. 

Nux vomica: — This is often the first remedy in 
peptic asthma that depends upon a reflex excitabil- 
ity of the pneumogastric nerve; the patient is of 
the irritable, malicious type, is easily offended and 
makes great mental efforts. Frequently, there is a 
history of stimulation with alcoholic beverages. 
He leads a sedentary life, is subject to frontal 
headaches, is dyspeptic, has a constantly sour 
stomach with much flatulency, and constipation of 
the bowels with frequent ineffectual urging to 
stool. There is a tendency to hemorrhoids. The 
cough is dry, spasmodic, and is attended with sore- 
ness in the epigastrium. He is always worse about 



ASTHMA^ 113 



3 a. m. As the attack passes off the tongue has 
a thick yellow coating, there is a slight nausea, 
with flatulency and constipation. 

Grindelia robusta: — The central characteristic 
of this remedy is that if the patient goes to sleep 
he loses his breath, and is awakened by the re- 
sulting suffocation; or the respiration becomes so 
irregular that his attendants waken him. In many 
of these cases there is present a catarrhal bronchi- 
tis upon which the asthma is dependent; the 
patient realizes that the raising of some mucus 
will bring relief. In many of these cases of 
asthma there is a history of repeated attacks of 
hay fever, pneumonia, and bronchitis. 

The iodide of ethyl, 10 to 15 drops, given by 
inhalation is of service in mild cases and in those 
associated with bronchial catarrh. 

Sulphur: — This remedy is frequently indicated 
in chronic asthma complicated with skin diseases, 
rheumatism, or other constitutional disorders. It 
may be of the dry or humid type, with rush of 
blood to the head and vertigo. There is a weak, 
faint sensation about 11 a. m. ; cannot wait for 
dinner. There is chronic constipation with bleed- 
ing hemorrhoids. The patient feels suffocated, 
wants doors and windows open, and has much 
burning of the soles of the feet and palms of the 
hands. 

Psorinum: — This remedy is adapted to psoric 
constitutions, when well selected remedies fail to 
relieve the case. The patient is pale and sickly, 
and the body has a. filthy smell even after bathing. 
There is great sensitiveness to cold air and changes 
of the weather. He always feels best the day 



114 ASTHMA. 



before the attack. All excretions have an offensive 
carrion-like odor. The asthma is worse in the open 
air and from sitting up. It is relieved by lying 
down. 

Ipecacuanha: — This is one of the first remedies 
to study in recent cases, particularl}^ in 3^oung 
people, when the result of inhaling dust or other 
irritants. There is a constant desire to vomit, but 
there is no relief from vomiting. The face is pale, 
the chest full of mucus but coughing does not re- 
lieve it and suffocation may threaten at times; the 
patient loses his breath when he coughs. 

Aconitum: — This is of service during acute 
attacks, its sphere of usefulness being soon over. 
The attacks are produced by cold, dry air or ex- 
posure. 

Bromium: — In the asthma of sailors; as soon as 
they go on shore there is spasmodic constriction 
that prevents breathing. 

Moschus: — This remedy is of great service when 
the hysterical and neurotic elements are prominent 
in the case. The patient believes suffocation will 
take place the constriction about the chest is so 
intense. 

Bryonia: — When this remed}^ is indicated there 
is a bronchitis present with sharp pains about the 
chest, which are worse from deep inspiration and 
from motion. 

Sambucus nigra: — The attacks appear suddenly 
at night, the child turns blue, gasps for breath, and 
seems as though dying; drops off into another 
sleep and awakens in another attack. There is dry 
heat while sleeping, followed by profuse perspira- 
tion upon awakening. 



ASTHMA. 115 



Cuprum: — This remedy is to be studied when 
the spasmodic character of the asthma is the prin- 
cipal feature of the attack, coming and going sud- 
denly. The face is blue, there is a sensation of 
constriction about the throat, with intense dyspnea, 
retching and vomiting. 

Aspidospermine: — This remedy is of service in 
cases of nervous origin, the d3^spnea being pro- 
nounced. 



CHAPTER XIII. 
HAY ASTHMA 



Definition: — This is the term applied to an 
asthma which appears during the course of an 
attack of hay fever. 

Etiology: — The causes are exciting, constitu- 
tional, and local. The exciting causes are the 
pollen of graminaceous plants, dust, smoke, or other 
irritants acting upon the nasal mucous membrane 
of those in a neuropathic state. In many of these 
cases there is a predisposition to asthma prior to 
the hay fever. This may be demonstrated by find- 
ing in the bronchial secretions both the pollen and 
the asthma crystals. 

Symptoms : — Hay asthma is usually a late symp- 
tom in hay fever, seldom appearing before the 
catarrhal symptoms have somewhat abated, which 
is usually about the end of the fourth week. It is 
more common during the autumnal form than in 
in those cases that appear earlier in the season. 
The patient suffers from lassitude, insomnia, and a 
chilliness that may alternate with a slight fever. 
The signs are very similar to those observed in 
ordinary asthma. In some cases it shows marked 
periodicity, occurring at the same time each year; 
in these cases there is some bronchial irritation 
preceding the attack. The attacks are not always 
of equal severity, and may be much milder for a 
few years in succession, and then return with 
greater severity. 



HAY ASTHMA. II7 



Sequelce: — In cases that have been compHcated 
with asthma for several years the heart becomes 
affected, and is weak and irregular during the 
attack, after the subsidence of which it may re- 
cover to some extent; in many cases a dilatation 
remains. 

Diagnosis: — This is dependent upon the asthma 
appearing during the latter part of an attack of 
hay fever, the coryza in neurotic subjects, and time 
of appearance, usually occurring during the month 
of August. 

Prognosis: — While the disease does not kill, 
the chances for a permanent recovery are not good; 
this is due to the difficulty of removing the under- 
lying neuroses, and of persuading the patient to 
place himself under treatment for a sufficient length 
of time to effect a permanent cure. The attack 
may appear at a later period than usual, or it may 
be lighter than previously, or absent entirely for 
one or more 3^ears. 

Treatment: — In a proportion of these cases the 
lesion, through which this disease expresses itself, 
is in the nose; this should receive the treatment 
recognized for such. 

Ascertain, if possible, the particular pollen that 
is responsible in the individual case, and then move, 
during the pollen producing period, to a region 
where this plant does not grow, and if possible re- 
main there. There are many plants the pollen of 
which has the power of produciug this irritation. 
Blackley claims there are seventy-four. 

Great altitudes are generally beneficial, and cer- 
tain regions are said to be free from the existence 
of pollens; Mackinaw, the White mountains, and 



Il8 HAY ASTHMA. 



sea islands that are at least twenty miles from 
shore. Respirators and dampened handkerchiefs or 
towels may be worn to protect the mucous mem- 
brane from the irritation. 

Noxious material, the result of imperfect diges- 
tion has a tendency to rid itself through the mucous 
membrane and to produce a vaso motor disturb- 
ance. The elimination of this material may be a 
factor in the etiology of some of these cases, and 
demands a treatment regulating the diet and habits. 
The diet should be simple, nutritious and non-stim- 
ulating. When the vasomotor disturbance manifests 
itself by taking cold easily, and there are present 
blueness or pallor of the spine, cold hands and feet, 
hydrotheraphy is indicated, and much benefit will 
be derived from either a full bath or cold spinal 
douches. Some of the cases are covered by that 
general term neurasthenia; a part of these demand 
rest, both physical and mental, while others require 
exercise according to the particular case. In other 
cases the rheumatic poison is operative and must 
be removed. 

The prophylactic treatment should not be post- 
poned until a few weeks before the time for the 
attack. The nervous system of these patients is 
below par, and the treatment should continue 
throughout the year, in order that the whole sys- 
tem may be brought up to a high physiological 
standard and maintained there. The habits should 
be investigated and all alcoholic beverages and 
stimulating articles stopped. There should be free- 
dom from all worry and anxiety. There is no 
doubt but that a portion of the benefit these pa- 
tients derive from a change of climate is due to 



HAY ASTHMA. II9 



the fact that their daily cares and burdens are left 
behind. In many of these cases it will be found 
advisable to restrict the amount of nitrogenous food 
consumed; in some cases stopping it altogether 
while the amount of carbohydrates is increased, as 
well as the quantity of water taken. 

Ambrosia artemisisefolia : — This remedy produces 
a typical picture of certain forms of hay fever and 
asthma. There is inflammation of the mucous 
membrane of the nose; at first there is dryness, but 
later there is a watery discharge that involves the 
frontal sinuses, and it is attended with sneezing and 
at times nose bleed. The inflammation extends to 
the trachea and bronchial tubes giving rise to 
asthmatic attacks. 

Sinapis nigra: — This remedy should be studied 
in cases of hay asthma when the mucous membrane 
of the nose is dry and hot; the nostrils are dry, 
with thick lumpy secretions. What little discharge 
there is, is acrid. The left nostril is most fre- 
quently stopped up and dry, or the nostrils are 
alternately stopped up. 

Arsenicum iodatum: — This remedy is said to be 
prophylactic in many cases. It produces a corrosive 
discharge that irritates the tissue over which it 
flows. There is much prostration. The face is 
pale with burning dryness of the larynx, and the 
cough is suffocating, with a tendency to asthma, 
especially after midnight. One grain of the 2x or 
3X should be given three times a day for a week 
or two before the attack. 

Naphthalinum, (ix or 2x): — This remedy has 
rendered' valuable service in those cases of hay fever 
where asthma is an important symptom. There is 



I20 HAY ASTHMA. 



much sneezing, the eyes are inflamed and painful, 
and the head hot. The asthma is spasmodic in 
character and is better in the open air. There is 
much soreness of the chest and abdomen, so patient 
must loosen his clothing to relieve the pain. 

Sabadilla: — This is adapted to persons with light 
hair, fair complexion, and a weak, relaxed muscular 
system. There is sneezing with copious watery 
cough and lachrymation; the face is hot, and the 
eyelids red and burning. The sneezing and lachry- 
mation are worse in the open air and from bright 
lights. The remedy may be used both locally and 
internally. 

Chininum arsenicosum: — There are severe dart- 
ing, tortuous pains running through the head; with 
intense photophobia, and gushing of hot tears from 
the eyes, ringing in the ears, and a constant dis- 
charge of fluid from the nose when out of doors 
but no discharge indoors. When in the open air 
the throat feels sore and inflamed, and is made 
worse by coughing and sneezing. There is hoarse- 
ness, with aching in the bronchial region, and a 
general weariness with great prostration. 

Psorinum: — Some of the happiest surprises in the 
practice of medicine have been from the use of this 
remedy. I believe I have demonstrated its useful- 
ness in this disease, not so much at the time of the 
attack, but between the attacks, in scrofulous ner- 
vous patients, where there is a lack of reaction 
after disease, and other remedies have failed to per- 
manently improve the patient, who looks sickly, 
pale, and emits a disagreeable odor from the body. 



HEMOPTYSIS. 121 



HEMOPTYSIS. 

Synonym : — Broncho-pulmonary hemorrhage. 

Definition: — This term impHes the expectora- 
tion of pure blood whose origin is at some point 
between the larynx and the pulmonary alveoli. It 
is but a symptom, and not a disease in itself. 

Pseudo or spurious hemoptysis is a term applied 
to a hemorrhage which has taken place from some 
point outside, and gravitated into the trachea or 
bronchi, and has then been expectorated. 

Etiology: — Its most common cause is a hyper- 
emic condition of the mucous membrane of the 
bronchial tubes. This may or may not accompany 
a fatty degeneration of the blood vessels. In some 
cases there is inflammation and ulceration of the 
mucous membrane. It is frequently an early indi- 
cation of pulmonar}^ tuberculosis. Bronchial catarrh, 
plastic bronchitis, and bronchiectasis are frequently 
attended with hemorrhage when ulceration has 
taken "place. It is a result of certain forms of 
heart disease that produce a passive congestion of 
the lungs. Severe mechanical, thermal, and chem- 
ical irritants, as well as tumors of the lungs, hyda- 
tids, abscesses, scurvy, purpura, and hemophilia 
will give rise to hemoptysis. Vicarious hemoptysis 
occurs at times as a result of suppression or irreg- 
ularity of the menstrual flow. It also occurs in 
those with diseased mucous membrane as a result 
of going into a rarified air. Occasionally it results 
from the rupture of an aneurysm. 

Pathology: — Any of the pulmonary vessels may 
be the seat of the rupture, but in the majority of 
cases the hemorrhage is capillary in character. 



122 HEMOPTYSIS. 



After death the bronchial tubes contain more or 
less blood which may be fluid or clotted, and of a 
dark brown color; occasionall}^ some blood may be 
drawn into the alveoli. If the hemoptysis occurs 
some time before the examination, no traces of 
blood will be found. Should it depend upon a 
tubercular process, such a condition will be present,, 
and in advanced cases a large clot may be found 
filling a tubercular cavity in the lung. When it is 
dependent upon a heart lesion it is seldom due to 
a rupture of a blood vessel but to an embolic pro- 
cess. 

Sym^toins : — The hemorrhage usually appears 
suddenly; there is a sensation of something warm 
rising up under the sternum, an insipid, salty, bloody 
taste in the mouth, a faint cough, and the blood is 
expectorated. The irritation of the blood excites 
more coughing and there may be from an ounce to 
several quarts raised and ejected. Usually the 
hemorrhage is not accompanied by fever; on the 
contrary the temperature may be sub-normal. The 
blood is usually bright red ; the pulse becomes rapid 
and feeble; the expression of the face anxious, and 
the skin cold and clammy. When the hemorrhage 
is controlled, and reaction takes place, there often 
appears a febrile condition in which a temperature 
of 103° or 104° may be reached and small dark 
blood clots may be expectorated for several days. 
In some cases the patient may locate the spot over 
the diseased lung from which the hemorrhage oc- 
curred. 

All attempts at making a physical examination 
should be avoided at first, apart from palpation and 
auscultation, which may be practiced without dis- 



HEMOPTYSIS. 123 



turbing the patient and running the risk of renew- 
ing the hemorrhage; and while physical signs may 
give evidence of a liquid in the bronchial tubes, in 
many cases the signs are negative. 

Diagnosis : — While it is an easy matter to make 
a diagnosis of hemoptysis, it is not alwaj^s easy to 
state which of the causes are at work in each partic- 
ular case. Careful examination should be made to 
ascertain that the case is not one of pseudo-hemop- 
tysis; it must always be differentiated from hemate- 
mesis. 

HEMOPTYSIS. HEMATEMESIS. 

The blood tastes sweetish or Taste is masked by stomach 

salty. contents. 

Blood is coughed up. Is vomited up. 

Blood is bright red. Is dark. 

Is alkaline in reaction. Is acid in reaction. 

Stools are of a normal color. Are often tarry. 

Prognosis : — Usually the hemoptysis dependent 
upon the early stages of tuberculosis is recovered 
from, while later in the disease it may be fatal. 
Those cases that are dependent on aneurysm may 
be fatal. 

Treatment: — At the time of the hemorrhage 
the patient should be placed upon one side, in a 
cool room with the head and shoulders elevated, 
that expectoration may be rendered easier. He 
should be reassured as to his favorable condition and 
all attendants who are not capable of assisting in 
this assurance should be sent from the room. The 
patient should not make any muscular effort nor 
talk and if the feet are cold, heat should be ap- 
plied. If any food is administered during this time, 
it should be liquid, and cold. Small pieces of ice 



124 HEMOPTYSIS. 



may be dissolved in the mouth, and an ice bag 
appHed over the part of the lung supposed to be 
affected; the cold application should onl}- be mo- 
mentary as it is the sudden shock that is beneficial. 

Cold should not be used in the rheumatic. In 
some cases it will be found that heat in some form 
is more serviceable than cold, and in such cases a 
hot water bag, 120° F., applied to the cervical 
region is often beneficial. Patients who are subjects 
of acute or chronic inflammation of the respiratory 
organs should avoid cold and chilling, as well as 
physical over-exertion. Should they suffer from a 
severe cough it must be controlled so far as possi- 
ble. Should the cause be from a diseased heart 
this must receive attention. In cases of vicarious 
hemoptysis the effort should be to re-establish the 
normal menstrual flow. In severe cases, temporary 
ligations of the extremities that will obstruct the 
superficial venous circulation only, will be found of 
value. They may be allowed to remain for twenty 
minutes and then be removed cautiously. Fainting 
occurs in some cases and if there has not been a 
great loss of blood, leave the patient alone and this 
will lower the circulatory tension. Should a large 
quantity of blood be lost it is advisable to use an 
injection of normal salt solution. A tablespoonful 
of common table salt dissolved in half a pint of 
cold water and swallowed by the patient has given 
good results; the dose may be repeated. 

Aconitum: — When the hemoptysis appears after 
exposure to a dr}', cold air; the patient is of a 
plethoric habit, and has a tendency to palpitation of 
the heart, with burning, stinging pains in the chest. 
The cheeks are flushed, the pulse is excited, and 



HEMOPTYSIS. 125 



there is great restlessness with anxiety and fear of 
death. 

Veratrum viride (ix): — -This remedy is to be 
thought of in cases where there is great pulmo- 
nary congestion, and the temperature is high, 104°; 
the pulse is hard, full, quick, and bounding, and the 
respirations are short and rapid. Under this remedy 
the arterial symptoms predominate; under aconite, 
the nervous symptoms. 

Hamamelis: — The patient who requires this rem- 
edy in hemoptysis is subject to passive venous con- 
gestion; there are varicose veins, ulcers, and hemor- 
rhoidal pains; he takes cold easily from exposure to 
warm, moist air. The hemorrhage may be con- 
stant, of a small quantity, dark in color, and comes 
up without effort or coughing. 

Geranium maculatum: — This remedy in doses 
of from ten to twenty drops, repeated every fifteen 
to twenty minutes has frequently been serviceable 
in cases complicating tuberculosis, and where there 
existed a catarrhal condition of the bronchial mucous 
membrane. 

Millefolium: — This remedy is of benefit in cases 
of pulmonary tuberculosis where there are cavities. 
The hemorrhage is profuse, the blood is bright red, 
with but little cough. It is to be compared with 
arnica in hemorrhage due to trauma. 

Ipecacuanha: — There is the constant and contin- 
ual nausea, with hard, heavy, oppressed breathing. 
The hemorrhage is profuse, the blood of a bright 
red color. The least motion aggravates the hemor- 
rhage. 

Ferrum: — The patient is pale and anemic, the 
face becomes fier}^ red on the least motion, the 



126 HEMOPTYSIS. 



Stools are undigested and there is edema of the feet 
and legs. The blood is bright red, and there are 
pains through the chest and between the shoulders. 
At times ferrum phos. will act better than the fer- 
rum in those who are growing rapidly. 

Phosphorus: — In the typical tall slender in- 
dividual with lively perceptions, inclined to stoop; 
the patient is of the tubercular diathesis. The 
cough is dry, with trembling of the whole body, 
tightness of the chest, weakness, and emptiness of 
the abdomen. The hemorrhage is profuse; will 
cease for a time and then return. 

Hydrastis canadensis: — This remedy will be 
found serviceable in those cases where there is gen- 
eral debility with catarrhal, ulcerating, aphthous, 
indolent and unhealthy condition of the mucous 
surfaces. There is an atonic dyspepsia with chronic 
constipation and hepatic congestion. Hydrastine 
hydrochlorate will be found to give good service. 

Acal37pha indica ( 6x ) : — This has relieved 
hemoptysis occurring in the morning and consist- 
ing of bright red blood, later in the afternoon 
dark and clotted. The patient has paroxysms of 
coughing through the night, he feels exhausted 
in the morning, and gains in strength during the 
day. 

Digitalis: — When the hemoptysis is dependent 
upon an obstruction to the pulmonary circulation, 
the result of diseases of the heart. The pulse is 
slow and often irregular. There is blueness of the 
skin, of the eyelids, lips, tongue, and nails, with 
faintness or sinking at the stomach, as if he were 
dying. The respiration is irregular, difficult, and 
performed with frequent sighs. 



HEMOPTYSIS. 127 



Cactus grandiflorus : — The hemorrhage is depend- 
ent upon the heart. Its action is turbulent, and 
there is the constrictive sensation about the heart 
as of an iron band. 

Acidum sulphuricum : — This remedy has been 
successfully used for this condition when there was 
extreme weakness and exhaustion with a sensation 
of tremor all over the body without trembling. 
The mucous membrane is in an unhealthy condi- 
tion, the hemorrhage is not profuse but rather a 
steady oozing of dark colored blood. It will be 
found of most service in the aged, — particularly 
anemic women. 

Ergotinine, Tanret's: — When ergot or ergotine 
is indicated, this preparation in from three to ten 
minim doses, used hypodermatically, is of great 
service and will cause no irritation or inflammation 
of the connective tissue. 



CHAPTER XIV. 
BRONCHO - PNEUMONIA. 



Synonyms: — Catarrhal pneumonia; lobular pneu 
monia. 

Definition: — This is an acute inflammation of 
the pulmonary tissue, secondary to bronchitis, and 
marked by an indefinite and irregular course. It is 
characterized by an inflammation of the lobules and 
an exudation into the alveoli which consists of an 
albuminous liquid, degenerated epithelial cells, red 
blood corpuscles, and leukocytes. 

Etiology: — It occurs more frequently during the 
winter and spring months. This is the form of 
pneumonia met with among infants, children that 
are exposed to cold unsanitary surroundings, and 
those suffering from rickets, chronic diarrhea and 
scrofula. It is a frequent complication of the acute 
infectious diseases, especially measles, whooping- 
cough, influenza, diphtheria, typhoid fever, and 
smallpox. In these cases the alveolar structure is 
involved, either b}^ continuit}^ or aspiration of the 
bronchial secretions. Inhalations or insufflations of 
particles of food or other foreign material become 
active causes in those suffering from a low form of 
fever; and in the cases of the new born as a result 
of vigorous inspiratory efforts made while the head 
is descending through the vagina. Inhalations of 
steam and irritating vapors are active causes, espe- 
cially if the vapors hold decomposing organic matter 
in suspension; cutting of the vagus nerves, or tumors 



BRONCHO-PNEUMONIA. 1 29 

of any kind, by producing paralysis of vocal cords, 
allows the irritating secretions, particles of food and 
micro-organisms to be conveyed to the lungs during 
inspiration. 

Pathology : — This presents three distinct types ; 
(i) catarrhal broncho-pneumonia, (2) hypostatic pneu- 
monia, and (3) aspiration pneumonia. In the ca- 
tarrhal variety the lung presents distinct appearances 
in the form of dark, light red, or grayish lobular 
areas upon the pleural surface, which are harder 
than the surrounding tissue and are slightly elevated 
upon the surface. Around these areas there is a 
zone of emphysematous lung tissue, and occasionally 
between them, a depressed area, due to atelectasis. 
Usually both lungs are involved in the process; the 
consolidated areas are more numerous near the sur- 
face. The medium sized and smaller bronchi con- 
tain muco-purulent material which, upon section of 
the lung, may be squeezed out. The pneumonic 
area presents a smooth surface, except when there 
is a mixture of fibrinous pneumonia, when the cut 
surface will be granular. The area of collapse is 
dark red in color and from it a bloody liquid 
exudes on pressure. In the area of consolidation, 
the alveoli and air sacs are filled with liquid, 
epithelial cells, red blood corpuscles, and leukocytes. 
As resolution takes place the exudate becomes 
lighter in color as a result of fatty degeneration, 
and is expectorated or absorbed; in time the pul- 
monary tissue returns to a normal condition. There 
is always bronchitis preceding the development of a 
catarrhal broncho-pneumonia. It may extend from 
the bronchials by continuity, or by contiguit}' 
through the walls of the bronchi to the surround- 



I30 BRONCHO-PNEUMONIA. 

ing alveoli. In either case there results a localized 
catarrhal pneumonia about a terminal bronchia. 
The exudate may be fibrinous, purulent, or hem- 
orrhagic. 

Bronchitis is always associated with broncho- 
pneumonia; and while pleurisy is not as common as 
with croupous pneumonia, when it does occur 
there is a greater tendency in it to become puru- 
lent. At times instead of the usual termination, 
suppuration and gangrene may result, or purulent 
collections may develop in the lung, surrounded by 
an area of congestion and inflammatory edema. In 
other cases where resolution is slow, a proliferation 
of the connective tissue of the alveoli takes place, 
with a fibroid overgrowth of the septa, resulting in 
a contraction of the lung tissue which is known as 
secondary fibrinous pneumonia. 

Hypostatic pneumonia is a termination of differ- 
ent diseases, in which the posterior portion and the 
base of the lungs are principally involved. At the 
beginning of the process there is a hemorrhagic 
edema and a hypostatic congestion into the most 
dependent part of the lungs. In aspiration pneu- 
monia there is established a catarrhal or fibrinous 
inflammation in the terminal bronchioles and air 
vessels as the result of irritants that find their way 
down the bronchial tubes. 

Symptoms: — These depend on the etiology of 
the case, and as to whether primary or secondary. 
When primary it presents many of the symptoms 
of a severe case of acute bronchitis; there is fever, 
dyspnea, cough, and pain. When it appears in 
those who are weakly its onset is slow. The ex- 
pectoration that attends the cough is glairy and 



BRONCHO-PNEUMONIA. I3I 

tenacious, and may contain blood. In the severe 
cases the temperature may be high and continuous, 
but more frequently it is moderate, io2°F. to 103° 
F., is of an irregular type, and terminates by lysis, 
after a duration of from two to four weeks. 

When secondary the early symptoms are those 
of the preceding bronchitis. The first symptoms 
that should lead one to believe that broncho-pneu- 
monia is developing is the sudden increase in the 
respirations, increased dyspnea, a rapid, feeble, run- 
ning pulse, a quick rise in the temperature, the 
appearance of a more difficult cough, and cyanosis. 

Physical Signs: — Inspection. This shows an 
increased respiratory effort on both sides of the 
chest, with cyanosis that affects the lips and con- 
junctiva, while later the face becomes dusky and 
the finger tips blue. 

Palpation: — This soon shows defective expan- 
sion and an increased tactile fremitus over the 
consolidated area, and areas of increased vocal 
fremitus. 

Percussion: — In some cases there are small 
areas of dullness surrounded by a tympanitic area, 
while in other cases the areas of consolidation are 
too small to give rise to any dullness. 

Auscultation: — The breathing is broncho-vesi- 
cular with fine and large moist rales, mostly sub- 
crepitant in character, scattered over the whole 
chest. The vocal resonance and fremitus are in- 
tensified, corresponding, as a rule, to the area of 
percussion dullness. 

C 07)1 f lie atio7is and sequelce: — The course of the 
disease is slow; even cases that terminate favorably 



132 BRONCHO-PNEUMONIA. 

last from three to four weeks, and many of them 
longer, there being remissions and exacerbations. 
It may terminate in tuberculosis, especially those 
cases where it complicates pertussis or measles. 
Chronic interstitial pneumonia, abscesses, or gan- 
grene of the lung may result. Pleurisy is occa- 
sionally present and empyema may develop. 

Diagnosis : — In many cases this is arrived at 
more by inference than by actual demonstration. 
The clinical history of the case must be considered, 
the gradual onset, the fact that both lungs are in- 
volved, that there are greater evidences of bron- 
chitis than of consolidation; the marked dyspnea 
and cyanosis, with a temperature below that of 
lobar pneumonia; and the long duration and a de- 
cline by lysis. 

Prognosis: — This varies with the etiology of 
the disease; when secondary to diphtheria, measles, 
or whooping cough the prognosis is often grave, 
and those cases that depend on the inhalation of 
particles of food often prove fatal. 

The unfavorable symptoms are a high tempera- 
ture, continuous dyspnea, Cheyne-Stokes respira- 
tion, convulsions, delirium, especially if the disease 
has existed for some time and has an extensive in- 
flammatory process. The average mortality is from 
30 to 50 per cent. 

Treatment : — Cases of nasal catarrh and coughs 
should not be allowed to pass without treatment as 
they are liable to terminate in broncho-pneumonia. 
An active inflammation in connection with the de- 
praved condition of the system, calls for a form 
of general treatment that will be supporting.- The 
patient should remain in bed and change his posi- 



BRONCHO-PNEUMONIA. 



tion frequently, that lobular collapse may be 
avoided as far as possible. The room should 
be well ventilated and the temperature maintained 
at 70° F. or above. If the atmosphere of the 
room is dry, steam may be introduced by means 
of boiling water. If it is desired, compound 
tincture of benzoin, eucalyptus or turpentine may 
be added to the water. 

In cases where bronchitis is a prominent symp- 
tom, respiratory failure is frequently observed as a 
result of obstruction of the smaller tubes, and col- 
lapse of the lobules. Where this is feared active 
inspiratory exercises will benefit the patient, and 
prevent or delay its appearance. It will be found 
that cold baths or what is often better, dashing- 
cold water over the chest and spine provokes fur- 
ther inspirations, and assists in overcoming the 
danger of pulmonary collapse. Sponging with 
tepid water is often beneficial to the patient as it 
equalizes the circulation and allays the nervous 
symptoms. 

In cases where the pleura is involved and pain 
is complained of, hot, or at times, cold applica- 
tions will bring a degree of relief. The dyspnea 
that attends these cases is often partially relieved 
by the application of a cotton or woolen jacket 
that may be held in place by tapes; hot poultices 
of ground flax seed or corn meal, covered with 
oiled silk and changed every four or six hours 
may be employed, but great care must be exer- 
cised that they do not become cold and the pa- 
tient thereby chilled. A degree of relief is ob- 
tained by massaging the chest wall, especially the 
intercostal spaces, with vaseline or warm glycerine. 



134 BRONCHO-PNEUMONIA. 

The heart is taxed to its limit in some cases, 
when strychnine and other cardiac stimulants should 
be employed. 

When cyanosis appears inhalations of oxygen 
will be found of service. The patient should be 
encouraged to take all the fluid possible as it will 
assist in removing the inflammatory products from 
the bronchi. The diet should be light and fluid, 
but liberal and nutritious; consisting of milk, either 
plain, malted or peptonized, egg-nog, egg-albumen 
or other preparations that meet the requirements. 

Ferrum phosphoricum: — This is frequently the 
first remedy. There is active congestion of the 
lungs, but the fever is not high; the pulse is soft 
and full, the chest feels sore, and often a bruised 
sensation is complained of; the expectoration is 
scanty and may be blood streaked; upon ausculta- 
tion sonorous and sibilant rales are heard over the 
chest. Frequently the patient is cachectic and 
anemic. When the disease is ushered in -with a 
higher temperature and great arterial excitement, 
study veratrum viride. When with the high fever 
there is restlessness and anxiety, aconite should be 
studied. 

Gelsemium: — This remedy will give a most 
happy surprise where there is a convulsive, spas- 
modic cough in hysterical women. There is but 
little expectoration, the cough is violent but the 
secretions are limited. The patient complains of 
chilliness up the back, cannot move without a feel- 
ing of chilliness. There may be great restlessness, 
but a motor weakness is present which renders 
the patient unable to move, and yet the heart 
feels as though it would stop and she must move 
in order to keep the heart going. 



BRONCHO-PNEUMONIA. I 35 

Tartarus emeticus: — This is the most import- 
ant remedy in the treatment of broncho-pneumonia 
when the case is once established and there are 
large collections of mucus in the bronchial tubes. 
Expectoration is difficult, the rales may be fine or 
coarse, the respirations are rapid, the breathing is 
oppressed, there are indications of cyanosis, the 
lips are blue, the surface of the body is cold and 
often covered with sweat while the heart's action 
is feeble. 

Phosphorus: — This remedy will be found use- 
ful in cases where fatty degeneration is present. 
The febrile symptoms are not marked, but the 
patient may be suffering from Bright's disease, 
diabetes, or phthisis. They are the typical phos- 
phorus patients. 

Bryonia: — This is frequently the second rem- 
edy in the case. The patient desires to remain 
quiet, the cough is distressing, causes great pain 
in the head'^and chest, is worse at night so that 
the patient sits up, and even gets out of bed and 
holds his chest. There is thirst for large quanti- 
ties of water, while the bowels are constipated and 
there is incontinence of urine while coughing. 
Squilla is often the next remedy, where bryonia 
has not fully relieved its symptoms. 

Arsenicum album: — When in advanced cases 
there is marked prostration, all the vital forces are 
weakened and the heart's action is tumultuous. 
There are suffocative attacks with difficult and 
oppressed breathing, and there is edema or emphy- 
sema of the lungs present. 

Lycopodium: — Where there is but little expec- 
toration and the cough would indicate great 



136 BRONCHO-PNEUMONIA. 

amount of mucus in the lun^s. The patient is 
worse in the afternoon and of a lithemic diathesis. 

Mercurius solubilis: — When the cough is dry 
and racking. The patient is worse at night from 
the least draught of air, and from lying on the 
right side. 

Antimonium arsenicum: — In the aged, when the 
heart is feeble and there are loud rales. 

Scilla: — This remedy corresponds to many of 
the symptoms presented in a well marked broncho- 
pneumonia. It produces an inflammation that sim- 
ulates capillary bronchitis, and towards the end 
cardiac failure is present. It produces a cough 
which at first is dry, but later becomes loose, 
especially in the morning, and which is more 
fatiguing than the dry evening cough; the ex- 
pectoration may continue during the day. It is 
spasmodic, caused by mucus in the trachea or a 
tickling and creeping sensation in the chest. 
Headache is complained of, with dyspnea, in- 
voluntary micturition, and stitches in the chest 
while coughing. The cough seems to proceed 
from the lowest ramification of the bronchial 
tubes, and auscultation reveals this to be a fact. 
Every paroxysm of coughing winds up in sneez- 
ing, and involuntary urination. There are stitches 
in the side of the chest while inhaling and cough- 
ing. 

Antimonium iodatum: — This remedy should be 
studied in cases of bronchitis, humid asthma, and 
even those that simulate phthisis, where there are 
frequent spells of coughing, with expectoration of 
frothy white or yellow mucus. The fever is not 
high, there is loss of appetite and strength; the 



BRONCHO-PNEUMONIA. 137 

tongue is coated and there is disgust for food; 
the skin and conjunctiva are yellow. Often there 
is a history of chronic bronchitis with or without 
asthma. 



CHAPTER XV. 
CROUPOUS PNEUMONIA. 



Synonyms:- — Pneumonitis-, lung fever, lobar 
pneumonia, pleuro-pneumonia, fibrinous pneumonia. 

Definition: — This is an acute inflammation of 
the parenchyma of the lung, of infectious origin, 
characterized by a localized pulmonary lesion, and 
marked constitutional symptoms, 

Etiology: — It is most prevalent from November 
to May, and in warm rather than cold climates. 
On account of their exposure four men suffer 
from it to one woman. It is frequently found in 
the weak and debilitated and in those who have 
faulty hygienic surroundings. At times it appears 
as a sequela of malaria and other infectious fevers, 
as a complication following an injury, and in cases 
of gout. Cold and exposure produce a condition 
in the lung favorable to the development of the 
diplococcus pneumonia or pneumococcus of Frankel, 
which is the cause of pneumonia. It is the most 
fatal of all diseases after sixty years of age. 

Pathology : — It is customary to divide the 
pathological process of pneumonia into the stages 
of engorgement, red and gray hepatization, puru- 
lent infiltration, and resolution. During the stage 
of engorgement the pulmonary vessels are dis- 
tended with blood, the circulation becomes slug- 
gish, and stasis ensues; as a result, the portion of 
the lung affected becomes enlarged, edematous, of 
a deep red color, and pits upon pressure, but it 



CROUPOUS PNEUMONIA. 1 39 

Still contains some air. Within the air vesicles are 
red blood corpuscles, leucocytes, and larg-e flat- 
tened epithelial cells. The vessels of the pleura, 
covering the affected area of the lung, are also 
congested. 

As red hepatization takes place the enlarge- 
ment is more pronounced, so that an impression 
of the ribs is to be seen upon the lungs. The 
consolidation is now complete, so that upon firm 
pressure the lung breaks, leaving a granular sur- 
face; it does not crepitate but it sinks in water 
showing an absence of air. Upon section the 
surface is of a dark, reddish brown color, and, 
upon scraping, a rusty red fluid exudes. The 
microscope shows the alveoli to be filled with 
a fibrinous exudate, in the interstices of which 
are red blood corpuscles, leucocytes, together 
with proliferated epithelial cells from the alveoli. 
The pleura over the diseased area is either cov- 
ered with a layer of lymph or there is an exu- 
dation of a clear, turbid, or blood stained fluid. 

Owing to an increased exudation of leucocytes 
there is pressure upon the alveolar walls, which 
empty the blood vessels; this, together wath an 
absorption of the red corpuscles by the leucocytes, 
results in a change in the color of the hepatized 
lung, which is known as grey hepatization. Dur- 
ing this period the granular character of the lung 
is not as distinct, the consolidation is less firm, 
the fluid exuded from the cut surface is now of a 
milky yellow, or purulent color, and the bronchi 
may be filled with a cylindrical cast of fibrin. The 
microscope shows that the exudate does not com- 
pletely fill the air cells; that the red blood cor- 



140 CROUPOUS PNEUMONIA. 

puscles and fibrin have been replaced by leucocytes 
which form opaque masses within the alveoli. 
There is a moderate degree of infiltration of the 
alveoli walls with leucocytes while the blood ves- 
sels are almost empty. As the process advances 
the lungs become softer, of a more distinctly yel- 
low color, and break down more easily, having 
lost their granular appearance; the fluid being de- 
cidedly purulent, the term purulent infiltration is 
now applied. This is but a part in the process 
from grey hepatization to resolution. 

Resolution: — During this stage the exudate 
undergoes a fatty degeneration, breaks down and 
is converted into a liquid that is to a great extent 
absorbed by the lymphatics; a small portion of it 
is removed by expectoration. 

Abscess: — Should the inflammatory process be 
very severe, and the blood supply injured, the 
vitality of the part is so reduced that it under- 
goes necrosis and is disorganized. A portion of 
it is expectorated with a large quantity of pus, 
and as a result an irregular cavity occupies the 
side of the previous inflammatory process. The 
only other unfavorable termination of pneumonia, 
met with frequently enough to demand recogni- 
tion, is gangrene. 

Symptoms : — In the great majority of cases the 
onset is sudden, yet in some cases there is a his- 
tory of bronchial catarrh and malaise having ex- 
isted for a few days. Its advent is announced by 
a decided chill which is followed by a high fever, 
flushing of the face, headache with nausea, vomit- 
ing, and with delirium and convulsions in children. 
Pain is present in all cases except those of central 



CROUPOUS PNEUMONIA. I4I 

pneumonia, its usual location is in the side, but 
it may be in the lumbar and iliac region; and is 
aggravated by coughing, deep inspiration, and 
motion of any kind. 

In a typical case the patient within a few 
hours (20) lies upon the back or inclines towards 
the affected side as this limits the motion of the 
parts, and thus relieves the pain. There is usually 
great prostration and restlessness, the face presents 
an expression of anxiety, the eyes are bright, the 
cheeks are either crimson or purplish in color, 
while a crop of herpes may be present on the lips. 
The temperature is high (104° to 105°) and pre- 
sents but little, if any, morning remission. The 
skin is dry and hot and may remain so until the 
time of the crisis. The respirations are greatly 
increased in frequency, being from 30 to 50 to the 
minute. Should the pain be severe the breathing 
will be shallow, and irregular, while dyspnea and 
a feeling of oppression may be complained of 
about the chest. 

Early in the history of the case there may be 
but little cough, and that, short and hacking in 
character. The pulse, although increased in fre- 
quency is not increased in proportion to the respi- 
rations, and instead of the normal relation of 4 to 
J it may be 2 to i. The appetite is lost, but 
there is great thirst. At the beginning of the 
disease the tongue is covered with a w^hitish coat 
which in a few days changes to a brown color, 
and even to a black in those cases where the ner- 
vous symptoms predominate. 

The urine is decreased in quantity, is of a high 
color and of a high specific gravity, contains an 



142 CROUPOUS PNEUMONIA. 

excess of urea and uric acid; the chlorides are 
markedly diminished or absent; albumen may be 
present, also blood and fibrinous casts. The ex- 
pectoration during the first few days consists of a 
frothy mucus, but by the third day it becomes thick, 
tenacious and of a rusty color, due to the red 
blood corpuscles it contains; in the aged and alco- 
holic it may be of a prune-juiced color, which is 
not a favorable sign. Under the microscope the 
sputum is found to contain blood corpuscles, epi- 
thelial cells, both the columnar and pavement vari- 
eties, pneumonococci, mucoid cells, granular cells, 
and oil globules. A chemical examination shows 
the alkaline phosphates to be absent, an ex- 
cess of the potash over the soda salts, and an in- 
crease of the sulphuric acid; the fixed salts, espe- 
cially the sodium chloride, are increased. 

The disease pursues a steady course until from 
the fifth to the eleventh day; usually about the 
seventh, it terminates by crisis or lysis. In cases 
of the former method of termination, the symptoms 
may assume a more threatening type, when the 
patient breaks out into a profuse general sweat, a 
diarrhea or a copious discharge of urine takes 
place and the temperature drops to normal or 
lower; the expectoration becomes lighter; the pulse 
more regular; the pain disappears; and improve- 
ment is noted in every particular. In other cases 
the temperature drops gradually, when it is termed 
lysis. 

Acute pneumonia in the aged and those with 
great lowering of the nervous vitality is often mis- 
taken for typhoid fever, as the cough, expectora- 
tion, pain, and in some cases the dyspnea, may 



CROUPOUS PNEUMONIA. I43 

all be absent. In these cases the physical exam- 
ination of the lungs must be relied upon. In the 
alcoholic, the symptoms of pneumonia may simu- 
late those of delirium tremens and in such cases a 
careful physical examination is also demanded. 

Physical Signs: — Usually within twenty-four 
hours there is physical evidence of consolidation 
taking place, and yet in some cases this may be 
delayed two or three days in cases that are not 
central. 

Inspection: — The patient usually selects the 
affected side to rest upon; the cheeks show a cir- 
cumscribed flush which may be purple in some 
cases, while there is a general pallor; or the face 
may be of a sallow hue; the lips are deep red at 
first, but later are cya nosed and pale at the time 
•of the crisis; herpes are present upon the lips and 
in some cases upon nose and cheeks. Should 
there be profuse sv/eating, sudamina will be no- 
ticed, as well as a degree of jaundice. Early the' 
eyes are bright, while later they are dull. There 
is a rapid loss of flesh; in some cases there is 
delirium and subsultus tendinum, and convulsions 
may be observed in children. The movements of 
the affected side are restricted, while there is a 
corresponding exaggeration of the movements of 
the healthy side. In double pneumonia the respi- 
ratory movements are largely diaphragmatic. The 
respirations are increased in frequency while dys- 
pnea of a panting character is present. Inspira- 
tion is short and superficial, w^hile expiration is 
often attended with a grunt. The cough is fre- 
quent, short, hacking, and is dry during the early 
stages but later it is loose. 



144 CROUPOUS PNEUMONIA. 

Palpation: — The skin is hot and dry until the 
crisis, and tenderness may be complained of; while 
the vocal fremitus is not changed during the first 
stage, it is increased during the second stage, ex- 
cept in those cases where a pleuritic effusion inter- 
venes, or the pneumonia is central and the main 
bronchi are blocked. During the third stage there 
is a gradual return to the normal. In those cases 
where a fibrinous pleurisy complicates the pneu- 
monia a friction fremitus is present. The apex 
beat is slightly displaced from the affected side. 
The pulse is somewhat increased; at the beginning 
it is full and bounding but in a few days it be- 
comes compressible, small, weak, intermittent and 
dicrotic. 

Percussion: — This varies with the stage of the 
disease. Dullness is recognized by the end of the 
first stage except in central pneumonia. During 
the second stage there is marked dullness over 
the consolidation, together with a sense of resist- 
ance to the pleximeter finger. The healthy lung 
gives a hyper-resonant note, while a tympanitic 
note is heard at times over the healthy lung in 
proximity to the consolidation, and over a consol- 
idated area in proximity to the trachea or main 
bronchi. At times a cracked-pot note may be 
heard when there is a relaxed condition of the 
lung adjacent to the consolidation. During the 
third stage normal resonance is established but 
this may take several weeks. 

Auscultation: — During the early part of the 
first stage the respiratory sounds are feeble, dry, 
and harsh over the affected area, while later they 
are broncho-vesicular. As the second stage ap- 



CROUPOUS PNEUMONIA. 1 45 

pears the breathing becomes bronchial if the large 
bronchus be patulous, while over the healthy lung 
tissue there is exaggerated breathing; during the 
third stage it becomes broncho-vesicular with a 
gradual approach to the normal. During the first 
stage the vocal sounds are normal; in the second 
stage bronchophony and pectoriloquy are present 
when consolidation is complete; while aegophony 
is present at the upper border of a slight pleu- 
ritic fluid, As the third stage appears broncho- 
phony and pectoriloquy give place to an exagger- 
ated vocal resonance. Rales may be heard during 
the first few hours of the disease, providing the 
stages have not followed each other closely; they 
may not be present during the second stage, but 
are present during the third stage. 

Varieties: — Migratory pneumonia is a term 
applied to those cases in which the hepatization 
affects one part of the lung after another and the 
parts in succession, passing through the different 
stages of the disease. The fever either remains 
constant, or shows remission and exacerbation as 
another portion of the lung is involved or the 
other lung is attacked. 

Typhoid pneumonia: — This term is used in a 
double sense; it may be applied to an adynamic 
form of pneumonia with typhoid symptoms, or to 
an occurrence of pneumonia during typhoid fever. 
It occurs in those who are much exhausted and 
are in depraved health, and in those who are liv- 
ing in unhygienic surroundings. It is found in 
cases of Bright's disease, septicemia, in drunkards, 
and is frequently seen among the Negroes of the 
Southern States. 



146 CROUPOUS PNEUMONIA. 

The characteristics of this form are the great 
physical prostration, the weak heart action, the 
high fevers, the frequency of the respiration and 
pulse, the marked delirium, and frequent vomiting. 
The skin has a dusky hue, the tongue is heavily 
coated or may be dry and brown, while sordes 
collect on the teeth. The sputum may be the 
usual prune juice color, or it may be nearly pure 
blood. It may be rapidly fatal, or the patient 
may linger for a long time and recovery be very 
slow. The prognosis is always grave. 

Bilious pneumonia: — This is a term applied to a 
type of pneumonia in which there is the occurrence 
of jaundice with the pneumonia. The chill is of 
longer duration, the pain in the side is more pro- 
nounced, due to the pleurisy, the fever is more 
remittent and jaundice and vomiting are present. 
Many of these patients are suffering from malarial 
poisoning. 

Ephemeral pneumonia is a term applied to the 
early symptoms and signs of pneumonia that end 
within forty-eight hours; the stage of hepatization 
not having been reached. 

Abortive pneumonia is where the stage of hepat- 
ization has occurred, but resolution follows immedi- 
ately and convalescence occurs on the third or 
fourth da}^ 

In apical pneumonia the symptoms are often 
pronounced, especially the nervous. The course of 
the disease is slow and resolution is delayed. 

Central pneumonia: — In this variety the rational 
signs are present, but the physical signs are absent 
with the possible exception of bronchophony. 

In pneumonia of infants the nervous symptoms 



CROUPOUS PNEUMONIA. I47 

predominate. There are repeated convulsions with 
delirium, torpor and coma. There is but little 
cough, no sputum, and the disease is usually located 
at the apex. In the aged the physical signs are not 
marked; there is a tendency to a typhoid state, 
with but little cough and expectoration. 

In the alcoholic, the pain, cough, expectoration, 
and dyspnea may all be absent; the temperature is 
elevated, and delirium tremens is present. 

Cofuplications and Sequelce: — Pneumonia is 
more uniform than most of the febrile diseases, and 
presents but few complications. 

Hyperpyrexia: — While the teniperature of pneu- 
monia is high it is seldom above io6°F., and 
death from this cause is not common. 

Bronchitis frequently accompanies pneumonia. 
It affects the larger bronchi and is the cause of 
the numerous coarse rales heard during the early 
and late stages of pneumonia. 

Pleurisy: — This is a part of the disease, and is 
not, in a strict sense, a complication. Apart from 
the pain it causes, the fibrinous exudate is of but 
little importance, and usually the serous exudate is 
not of any great amount and seldom demands at- 
tention, but at times after the pneumonia has sub- 
sided the dullness may continue, and the temperature 
rise again; this is usually due to a fluid in the pleu- 
ral cavity. As a rule this is purulent, giving rise 
to empyema which may in time be absorbed if 
the result of a diplococcus infection, but will not 
be absorbed if streptococci are found. 

Pericarditis: — This is a serious complication, and 
when found with double pneumonia is nearly always 
fatal. It occurs during the height of the fever and 



148 CROUPOUS PNEUMONIA. 

is accompanied by friction sounds which are to and 
fro, according to the heart's action. The effusion 
may be plastic, serous, or purulent. The pulse is 
small and irregular; orthopnea or dyspnea are 
present but the pain is not increased. 

Malignant endocarditis is a grave complication; 
it is most frequent in those cases that develop 
empyema. 

Acute meningitis has been observed in a few 
cases, especially where acute ulcerative endocarditis 
is present. Ulcerative colitis is a rare complication. 

Epistaxis is at times present at the onset of 
pneumonia, and may recur from time to time. It 
is not a serious symptom except in the aged. 

Arterial embolism in various parts of the body 
is an occasional complication; while peripheral neu- 
ritis, arthritis, parotitis, suppurating orchitis and 
haematuria are rarer complications. 

Secondary pneumonia: — This a term applied to 
a lobar hepatization that develops during the course- 
of some acute or chronic disease. Histological and 
bacterial investigation, and the eye are unable to 
make any distinction between primary and second- 
ar}^ pneumonia so far as the morbid anatomy is 
concerned. It is most frequently met with as a 
complication of typhoid fever, smallpox, erysipelas, 
septicemia, and chronic affections. It differs from 
the primary form in being more dangerous, and 
while the morbid anatomy and physical signs ma}' 
be similar, the initial chill is often absent. The 
temperature is not so high, and the cough may be 
wanting, while pleurisy may be present. 

Diagnosis: — This is based upon an aggregation 
of all the symptoms, which are usually so charac- 



I 



CROUPOUS PNEUMONIA. 1 49 

teristic that the task is an easy one. The clinical 
history is to be reviewed. The sudden onset, the 
marked chill followed by a high fever, with but 
little variation between the morning and evening, 
the pain in the chest, the cough with the peculiar 
expectoration, the dyspnea, the abnormal ratio 
between the pulse and the respiration, the peculiar 
rapid breathing, the physical signs, and leucocy- 
tosis form a group of symptoms that are character- 
istic of pneumonia. In cases where the diagnosis is 
difficult the upper lobe of the lung should be care- 
fully examined; the characteristic signs of solidifica- 
tion may be slow in appearing; or the pneumonia 
may be central with normal lung overlying the dis- 
eased portion. In these cases leucocytosis is usually 
found upon examination of the blood; and the 
chlorides are absent from the urine or lessened in 
quantity. At times when the physical signs develop 
slowly it may be necessary to delay the diagnosis 
for several days. 

In children the symptoms presented may be of 
such a character as to suggest the existence of 
meningitis. Convulsions, delirium, and stupor 
appear, while the expectoration may be absent, and 
the cough, at times, not pronounced. In these 
cases careful physical examination of the lungs 
should always be made. In the aged the onset is 
insidious, the cough, expectoration and fever are 
not pronounced, while the cough may be absent. 
In the alcoholic the cerebral symptoms are marked, 
and the delirium tremens, the fever, the rapid res- 
piration without a corresponding pulse rate should 
always call attention to the lung as the seat of the 
trouble. In case of chronic wasting disease as can- 



I50 



CROUPOUS PNEUMONIA. 



cer, phthisis, diabetes, Bright's disease, and organic 
heart disease, the onset is much as in the aged, 
and a small pneumonic process may be attended by 
the gravest symptoms. In all these cases where 
fever appears without apparent cause the lung 
should be carefully examined, as the physical signs 
are often obscured by the enfeebled condition of 
respiration as a result of the primary disease. 



EDEMA OF THE LUNGS. 

Results from heart dis- 
ease, when compensation is 
disturbed during nephritis 
and general asthenia. 

Involves both lungs. 

Usually there is dropsy, 
with effusion into the serous 
cavities elsewhere. 



CROUPOUS PNEUMONIA. 

See etiology. 



2. Usually but one. 

3. Not a part of pneumonia. 



4. The sputum 
and abundant. 

5. The cheeks are pale and 
livid. 

6. There is usually no fever. 

7. Percussion-resonance is but 
little changed. 

8. Rales both large and 
small are heard all over the 
chest. 

9. The chlorides in the urine 
remain unchanged. 

10. Speedily terminates in 
recovery or death. 

CATARRHAL PNEUMONIA. 

1. The onset is slow. 

2. Most frequent in children, 
the aged, and debilitated. 



is frothy 4. Rusty or like prune juice. 



Are flushed. 



6. The fever is high. 

7. It is dull during second 
stage. 

8. May be present during the 
earlier and later stages. 

9. Absent or greatly dimin- 
ished. 



10. Duration seven 
days. 



to nine 



CROUPOUS PNEUMONIA. 

1. Is sudden. 

2. The robust. 



CROUPOUS PNEUMONIA. 



151 



3. The sputum is seldom 
blood streaked. 

4. Of long duration and 
a tardy convalescence. 

5. The physical signs are not 
well defined and irregular- 
ly disseminated. 

HYPOSTATIC CONGESTION. 

1. The result of an acute or 
chronic debilitating dis- 
ease, or heart disease. 

2. Is located at the base 
and most dependent por- 
tion of both lungs. 

3. Fever is absent. 

4. Respiration not blowing. 

5. Expectoration not bloody. 

PULMONARY INFARCTION. 

1. It is secondary. 

2. Area may be circum- 
scribed. 

3. Fever is slight. 

PULMONARY TUBERCULOSIS. 

1. It is chronic, its duration 
is indefinite. 

2. May have severe hem- 
optysis. 



3. Contains the tubercle- 
bacilli and yellow .elastic 
tiss'ie. 

4. Emaciation is marked. 

5. Fever has a wide varia- 
tion. 



3. Usually blood streaked. 

4. From seven to nine days. 

5. Well defined, usually lim- 
ited to the lower lobe of 
one lung. 



CROUPOUS PNEUMONIA. 



I. See etiology. 



2. Usually the base of one 
lung. 

3. The fever is high. 

4. Blowing. 

5. Contains blood. 

CROUPOUS PNEUMONIA. 

1. It is primary. 

2. May be diffused. 

3. The fever is high. 

CROUPOUS PNEUMONIA. 

1. Is an acute disease termi- 
nating by crisis in eight 
to nine days. 

2. The sputum mixed with 
blood, hemorrage only in 
the pneumonia, associated 
with influenza. 

3. Diplococcus pneumonia or 
the pneumococcus of Frank- 
el. 

4. Not marked. 

5. The fever is continuous 
and high. 



152 CROUPOUS PNEUMONIA. 

6. Upper lobe of one lung 6. Usually unilateral and 
at first, extending from lower lobe, 

this. 

Prognosis: — From sixteen to twenty per cent 
of the cases prove fatal, the mortahty depending 
upon the individual, the epidemic, and other condi- 
tions. Children usually recover from it while in 
the aged the prognosis is grave as well as in those 
adults who are enfeebled by disease and alcoholic 
habits. The prognosis is grave in those asthenic 
cases in which the symptoms of toxemia are marked 
with delirium, rapid respiration and feeble pulse. 
A few of the cases die before, but the majority 
during the stage of red hepatization, just before 
the crisis is due, while a few die a day or two 
after. The greater amount of tissue involved the 
graver the prognosis, a double pneumonia being 
worse than pneumonia of one lung and of one lobe. 
Apical pneumonia is more serious than pneumonia 
of the base. When it appears as a complication of 
emphysema, nephritis, heart disease and pregnancy 
the prognosis is grave; the later it appears during 
pregnancy the greater the prospect of a miscarriage 
and death. 

The prognosis is grave in adults when the pulse 
and respiration continue to increase in frequency, 
and when the tracheal rales continue in spite of the 
coughing; when the breathing is stertorous, there 
is a low delirium with muscular tremor, and prune 
juice expectoration. Pericarditis and endocarditis 
always render the prognosis grave. 

Of the immediate causes of death toxemia due 
to pneumotoxia is the most frequent, which, acting 
through the nervous system, results in cardiac in- 



CROUPOUS PNEUMONIA. 1 53 

competency. The blood is not sufficiently aerated; 
this results from the hepatization of the lung, the 
lA^eakened condition of the heart, and the superficial 
character of the respirations. The pulse is rapid, 
weak and irregular; the patient is cyanotic, becomes 
•drowsical and comatose, and dies. 

Treatment: — In managing a case of pneumonia 
the room in which the patient is to be cared for 
should be well aired, and if possible a temperature 
of 65° F. should be maintained except in cases of 
the young when it should be from 70° to 72° F. 
Too great an amount of clothing should not be 
used upon the bed, that undue sweating may be 
avoided. The patient should not be allowed to 
leave the bed until the fever has been at normal 
for several days and all the exudate removed. 

Baths will be found of service in allajang the 
nervous symptoms, cardiac weakness, and dyspnea 
that arise during the disease. Cold baths should 
not be used. Baths may be started at a temperature 
of 90° F., and be gradually lowered according to 
the sensitiveness of the patient, but seldom should 
they go below 80° F. With those who are debili- 
tated, with the young and the aged, tepid baths only 
should be used. The bath should not last over from 
eight to ten minutes at a time and if thought neces- 
sary may be repeated every six to eight hours. The 
attendant giving the baths should be competent 
otherwise more harm than good may result. If a 
full bath cannot be given a wet pack or sponging 
may be employed. 

When the pain is very severe, heat applied to 
the affected side often brings a degree of relief. 
This may be applied in the form of dry or moist 



154 CROUPOUS PNEUMONIA. 

applications; if the latter are employed, great care 
must be exercised that no chilling results. 

Where the dyspnea is excessive and asphyxia is 
threatened, inhalations of oxygen will give tempo- 
rary benefit but it will not cut the course of the 
disease short. When the pulse becomes weak,, 
rapid and unsteady in adanymac cases, especially in 
the aged, alcoholic stimulants are of service, but 
their benefit is greatly exaggerated. When used 
they should be given in small amounts, two to 
three ounces daily. The modern antipyretic treat- 
ment with analgesics is of doubtful utility. 

The diet should be nutritious, light and liquid.. 
If debility becomes a prominent symptom the diet 
should be increased. There is nothing that meets 
the demand as well as milk. It should be given at 
stated intervals and in definite quantities; the white 
of Qgg, koumiss, junket juices, broth, and light farina- 
ceous foods are also beneficial. If resolution should 
be delayed, strengthening food is demanded. When 
the crisis is past, a heavier diet may be returned 
to, but over-feeding should be avoided at all times. 

When headache is a marked symptom the ice 
coil or cold water bag applied to the head often 
brings relief. The effusion of pleuro-pneumonia 
seldom demands attention, but when it is pro- 
nounced it should be removed. Emphysema, whea 
recognized, should be aspirated at once, and after- 
wards drainage established. 

Pericarditis is not always easy to manage. If 
the effusion is embarrassing the heart, it should be 
aspirated; if purulent, the pericardium should be 
opened and drained. 

When there is circulatory depression, and the 



CROUPOUS PNEUMONIA. I 55 

blood pressure is becoming low, a saline injection 
of from one to two pints is frequently of assistance^ 
It may be repeated in from eight to twelve hours » 

When cyanosis is a marked symptom, inhala- 
tions of oxygen gas directly from the tank or from 
the nozzle every alternate ten minutes is of service. 
When some respiratory stimulant is demanded at 
once, hypodermic injections of strychnine or atro- 
phine render excellent service. A cotton jacket is 
of value, but will interfere with a proper examin- 
ation of the chest. 

The bowels should be thoroughly relieved, pre- 
ferably by high enemas. It should be ascertained 
if the urine is being passed in sufficient quantities^ 
and the bladder examined from time to time, as 
retention of the urine takes place in a low typhoidal 
form of pneumonia. 

Some cases are benefited by increasing the 
humidity of the atmosphere of the room, especially 
if it is very dry. This may be accomplished by 
means of an atomizer, or kettle of boiling water on 
the stove. The patient should be kept quiet and 
no excitement or compan}' be allowed in the room. 
Plenty of water should be taken; it may be flavored 
with fruit juices or anything that will not interfere 
with the recovery. 

When heart failure is apparent, more diffusible 
stimulants as champagne are demanded. When 
heart failure is being combated the quantity of 
liquor that may be consumed without producing 
s3^mptoms of alcoholism is astonishing. Brandy and 
whisky are the better alcoholic stimulants. 

Veratrum viride: — The writer's experience has 
been that this remedy is more frequently called for 



156 CROUPOUS PNEUMONIA. 

than aay other during the stage of congestion. 
There is great arterial excitement, with a hard 
and full pulse, and dyspnea; the face is livid, there 
is marked pulmonary congestion, and a hacking 
cough which may be dry or attended with a blood 
streaked expectoration. The temperature is high, 
the respirations are labored, there is apt to be a 
red streak through the center of the tongue, and a 
sinking feeling is complained of at the pit of the 
stomach. Good results are obtained by using the 
mother tincture. 

Aconitum: — This is another remedy that is called 
for during the early part of the stage of engorge- 
ment and during the initiatory chill. There is 
great restlessness with an anguish of mind that 
refuses to be comforted. The fever is high, the 
skin is hot and dry, and the face is deep red. The 
respirations are labored and there is a sensation of 
weight and pressure about the chest; there are 
stitches in the chest during motion and deep inspi- 
ration. The pulse is full and bounding. The cough 
is dry and racking, the expectoration is tenacious 
and blood-streaked. There is intense thirst; the 
urine is scant and highly colored and a severe 
headache is present. 

Ferrum phosphoricum: — This remedy may be 
the only one needed, especially in cases of secondary 
pneumonia and in those who are debilitated and 
suffering from phthisis, anemia, and other chronic 
diseases. The chill is not marked, nor does the 
temperature rise quickly. The nervous symptoms 
are not as pronounced as under aconite; on the 
contrary the patient is apt to be quiet, and drowsi- 
ness is present. The pulse is full, round, and soft; 



CROUPOUS PNEUMONIA. 1 57 

as the fever becomes high the respirations are short, 
hurried, and oppressed; the expectoration early 
becomes rusty or consists of pure blood. The 
bronchial symptoms are more pronounced than are 
those of pleurisy. 

Bryonia: — This remedy presents many of the 
symptoms of a marked case of pleuro-pneumonia, 
and is frequently the one indicated when the physi- 
cian is called. The patient desires to remain quiet 
but the d3^spnea is so great that he becomes anx- 
ious. There are severe shooting, cutting pains with 
painful cough, the expectoration being scanty and 
bloody. The mouth is dr}^, and the tongue has a 
white coating. There is great thirst. The stom- 
ach is disordered; and the liver is engorged. The 
bowels are constipated, the urine is high colored 
and scanty, and the pulse is hard and tense. The 
pleura is involved as indicated by the sharp pains 
which are better from lying on the affected side 
and from pressure and warmth, and are aggravated 
by motion, breathing, and coughing. Should this 
remedy not relieve the pleuritic symptoms, squilla 
and asclepias tuberosa may be studied. 

Phosphorus: — This remedy is to be studied in 
cases during the stage of hepatization when there 
is but little pain; the consolidation is not marked, 
but there is a large quantity of mucous secretions. 
The patient is thin, tall, delicate, feeble, cachectic, 
and there are great exhaustion and depression pres- 
ent. The fever is not marked but there is great 
oppression about the chest; the sputa is rusty or 
muco-purulent, and the symptoms may have a tend- 
ency to assume the typhoid type. 

Chelidonium majus: — ^ Frequently in bilious pneu- 



158 CROUPOUS PNEUMONIA. 

monia and the pneumonia of children this is the 
first remedy. It is the lower lobe of the right 
right lung that is involved. There is a constant 
pain under the inferior angle of the right scapula. 
Bilious symptoms are present as indicated by the 
tendency to jaundice; vomiting of bile, and a slimy 
yellow colored diarrhea. The temperature is 
high, there is palpitation and an irregular heart 
action. Following this remedy sanguinaria, euony- 
min, carduus, mercurius, or tartar emetic may be 
called for by the symptoms present. 

Sanguinaria: — The best results are derived from 
this remedy during the second and third stages of 
the disease. It may follow any remedy, but fre- 
quently it is indicated after chelidonium, when 
there is a tendency to a diffused suppuration and 
a hectic flush appears. The patient complains of a 
faint, weak feeling, especially about the heart. 
There is a circumscribed redness of the cheeks 
which is most pronounced during the afternoon. 
The extremities are at times cold, again they are 
hot. There is extreme d3^spnea when the patient 
desires to take a deep breath, but the attempt to 
do so causes a pain in the right side; he lies on 
his back, and there is a pain and burning in the 
chest, with stitching pains; the pulse is quick and 
small, and there is a cough with a rusty colored 
and offensive expectoration. 

Lycopodium: — This remedy should be thought of 
in cases that have not received proper attention, 
where suppuration has taken place, and hectic 
symptoms are present; there is a circumscribed red- 
ness of the cheek, the lips and tongue are dry and 
red, and show ulceration; he cannot endure the bed 



CROUPOUS PNEUMONIA. I5Q 

clothing, sweating brings no relief, and when cough- 
ing it sounds as though the whole parenchyma of the 
lungs were softening. The expectoration is muco- 
purulent in character, and is raised in mouthfuls. 
The alae nasi are distended and have the fan-like 
motion. When the inflammatory process has sub- 
sided and left the lungs in a condition of suppura- 
tion, this remedy may do good work. The patient 
is often worse from 4 to 8 p. m. 

Tartarus emeticus:— When the stage of resolu- 
tion has arrived this remed}^ will often assist, but it 
should not be used too early. There is great pros- 
tration of the vital forces with dyspnea and fits of 
suffocation which are followed by great prostration. 
The face is of an earth}^ or dirty bluish color, 
seldom red; there is a cold sweat over the body 
-and diarrhea is present. 

Hepar sulphur: — ^When during the stage of res- 
olution the expectoration becomes purulent and 
abscesses threaten, this remedy should be studied. 

Carbo vegetabilis: — When the pneumonia as- 
sumes a chronic form, and abscesses and frequently 
emphj^sema are present. The eyes are only half 
•open, the nose is cold and pinched, and the extrem- 
ities are cold and blue. The patient calls for more 
air and must be fanned; the pulse is small and diffi- 
cult to count; the abdomen is distended; the respi- 
rations are superficial; the breath is cold; the cough 
is rattling; and the expectoration is greenish, fetid 
and bloody. The diarrhea and all discharges are 
ietid. 

Mercurius: — This is one of the prominent rem- 
edies after chelidonium, and is of service in cases 
of bilious pneumonia, especially when complicated 



l6o CROUPOUS PNEUMONIA. 

with bronchitis. The process is upon the right 
side; the fever has subsided but the dyspnea and 
pain continue; the expectoration is blood-streaked. 
There are sharp shooting pains through the dis- 
eased portion of the lung; jaundice may be present^ 
and there is a diarrhea in which the stool is slimy 
and attended with tenesmus. 

lodium: — This remedy is to be thought of in 
cases of scrofulous individuals who have delicate 
skin and enlarged glands. The temperature is 
high; there is but little if any pain; the patient is 
very sensitive and irritable. During the stage of 
hepatization it is called for often when the apex of 
the lung is involved. 

Sulphur: — When the stage of resolution is de- 
layed and the high temperature continues after the 
completion of exudation. The process does not im- 
prove and purulent infiltration is feared. There is 
little or no expectoration while the amount of 
exudate is great. A forenoon aggravation is sig- 
nificant. 

When heart failure is threatening as indicated 
by the pulse, which may be dicrotic, or rapid, weak^ 
compressible, irregular, or intermittent, prompt 
measures are demanded to stimulate the heart. In 
many this is during the crisis, but in the aged, the 
alcoholic, and debilitated, it may be earlier. 

In those cases where a typhoid state is devel- 
oped, baptisia, rhus tox., arsenic, hyoscyamus, or 
agaricus may be indicated. 

THE HEART IN PNEUMONIA. 

During the course of the disease the heart should 
be watched carefully, for the success of the treat- 



CROUPOUS PNEUMONIA. l6l 

ment will depend upon the condition of the heart; 
and even if in a healthy condition it will be taxed 
as the pulmonary obstruction becomes more pro- 
nounced, while if there has been a valvular disease, 
fatty degeneration, dilatation, or other changes in 
the myocardium, the chances are^ just that much 
less favorable, and it is not astonishing that pneu- 
monia should be a grave complication in those with 
diseased hearts. It should always be borne in 
mind that it is not the left heart, but the right 
that has the burden in pneumonia. The veins 
are distended, the arteries empty, and as a result 
the radial pulse is not a guide to the condition of 
the circulation. The attention should now be 
devoted to the pulmonary valve, and while early in 
the disease the right ventricle is contracting vigor- 
ously, there is a strong recoil to the pulmonary 
artery. This valve has a clear sharp sound, and 
this characteristic will continue throughout if it is 
to terminate favorably; but should the pulmonary 
resistance be too great, the accentuation is lost, 
the sound becomes weaker and weaker and finally 
ceases to be heard, indicating that the muscular 
power of the right heart is exhausted which allows 
the pulmonary obstruction to become greater, and 
thus the cycle is completed. As this process is 
being completed it is indicated by the pulmonary 
obstruction, and the general venous congestions. 
The distended right auricle is indicated by the 
increased cardiac dullness to the right, and epi- 
gastric pulsations, distended veins, and depleted 
arteries; frequently the liver and spleen are enlarged, 
the intestines are congested and the kidneys are 
hyperemic. In many of these cases it is difficult 



l62 CROUPOUS PNEUMONIA. 

to hear the pulmonary valve sound on account of 
the bronchial rales. 

In the management of these cases there is no 
stereotyped plan that will meet all cases. It should 
be borne in mind that the venous system is already 
over-distended, and any form of treatment that in- 
creases the amount of venous blood to any marked 
degree is not indicated. Too much food is injur- 
ious as it increases the venous congestion, gives 
rise to flatulence, and interferes with respiration; 
the blood becomes over-loaded with nutritive ma- 
terial, so that the imperfect respiration is unable to 
act upon it in the process of sanguinification. Too 
heavy foods, even if liquids, often oppress the res- 
piration, and render the heart's action more la- 
bored. 

It is doubtful if there is any food that meets 
the requirements as well as milk; it may be mixed 
with some form of alkaline water and shaken well; 
if constipation is present it may be mixed with a 
farina gruel; if diarrhea is present mix it with rice 
water, or lime water; alcohol in some form is of 
service; it should not be given to the point of in- 
toxication, but sufficient to relax the arterial system, 
and a few drachms a day will accomplish this. 
Whatever form is used, it should be pure and not 
used to excess. Among the remedies that may be 
used are amyl nitrite, glonoine, and the nitrites of 
sodium and potassium. Amyl nitrite should be 
used in cases of emergency only, as its action is of 
short duration, while glonoine is longer in its action. 
The nitrite of ammonium, in ten-drop doses of one 
per cent solution, may be used. 



CHAPTER XVI. 
ACUTE CONGESTION OF THE LUNGS- 



Synonyms: — Active congestion, acute hyper- 
emia. 

Dejinztion: — This is an increased amount of 
blood in the lungs. 

Etiology: — The causes are similar to those giv- 
ing rise to pulmonary inflammations; as exposure 
to cold, irritations in the form of chemical fumes, 
irritating particles, heat, cold, accelerated heart's 
action, violent exercise in those with narrow, con- 
tracted chests, changes in the atmospheric pres- 
sure, as in ascending high elevations; the excessive 
use of alcohol, and of cold drinks when over- 
heated; or the sudden lowering of the atmospheric 
pressure, as is met with in croup and laryngitis; 
and the sudden checking of some natural flow. 

Patliology : — The lung contains more blood 
than is normal, so that upon section there exudes 
a red frothy fluid; there is less air than is normal; 
it is heavier, and does not pit as readily upon 
pressure. The blood vessels of the bronchi and 
air sacs are seen to be distended. In those cases 
where the congestion is local, edema of the lung 
may result. 

Symptoms: — Its onset may be marked by a 
chill, but the fever is slight; there is marked dysp- 
nea with cough and stitching pains; the expecto- 
ration is serous, usually bloody, or of a rusty 
color. The physical signs are not well defined. 



164 ACUTE CONGESTION OF THE LUNGS. 

Physical signs: — Inspection. Shows an in- 
creased frequency of the respiration and the dysp- 
nea. 

Palpation: — Confirms inspection, and shows in- 
creased fremitus. 

Percussion: — This reveals an impaired pulmo- 
nary resonance. 

Auscultation: — The breathing is bronchial in 
character and rales of a subcrepitant character 
may be present. 

Diagnosis : — This is based upon the sudden on- 
set, with labored breathing, without marked fever, 
and a history of some exciting cause. 

Differential diagnosis should be made between 
this and pneumonia. 

ACUTE CONGESTION. PNEUMONIA. 

1. Fever, if present, is not i. Fever is high. 

high. 

2. No pneumococci in the 2. Pneumococci present, 
sputum. 

3. Chill not pronounced. 3. Chill pronounced. 

Prognosis: — It is usually but a transient con- 
dition that terminates favorably in a short time, 
but should the congestion be intense it may ter- 
minate as quickly in death or in pneumonia. Its 
duration is from a few hours to three or four 
days. 

Treatment: — In the management of this condi- 
tion the cause should be ascertained if possible, as 
it may throw some light on the management of 
the case. The patient should be placed in bed, 
and an attempt made to equalize the circulation. 
If the extremities are cold, they should be sponged 



ACUTE CONGESTION OF THE LUNGS. 1 65 

with hot soda water and wrapped in warm blan- 
kets. Should the checking of some discharge be 
the cause, an attempt should be made to re-estab- 
lish it. The patient should be confined to a liquid 
diet consisting of milk, broths, etc., and the bowels 
kept in an active condition. Alcoholic stimulants 
are to be avoided as they aggravate the condition. 
Should the congestion be intense, benefit will be 
be derived from the application of a dry cup over 
the chest, of hot poultices, or fomentations. Of 
the remedies, one of the following is often suffi- 
cient. 

Veratrum viride: — When the respirations are 
rapid, with great arterial excitement, the pulse is 
hard, strong and quick. 

Aconitum: — The patient is anxious, tossing 
about, knows he is going to die; there is fever, 
with dry, hacking cough, and an expectoration of 
bloody mucus. 

Belladonna: — When the face is almost scarlet, 
the pupils are dilated, the carotids pulsating, and 
the congestion has appeared suddenly. 

Ferrum phosphoricum: — The onset is not so 
rapid as under the preceding remedies. The fever 
is high, the breathing is short, oppressed, and 
hurried. The expectoration consists of nearly 
pure blood. The patient is frequently anemic and 
exhausted. 

Phosphorus: — In the typical phosphorus patient, 
tall, slender, stooped, blonde, with quick lively 
perceptions, delicate eyelashes, soft hair, this 
remedy will be called for by the tightness across 
the chest, the extreme dyspnea, and but little or 
no pain, while edema of the lungs is threatened. 



l66 EDEMA OF THE LUNGS. 

Tartarus emeticus: — This is the remedy to be 
thought of in cases where the symptoms resemble 
pulmonary edema; there is dyspnea, with fits of 
suffocation so that he must sit up. Cough with 
appearance of large collections of mucus in the 
bronchial tubes, but which he cannot cough up. 

Digitalis: — This^ is to be considered in cases 
due to alcoholism. 



EDEMA OF THE LUNGS. 

Definition: — This is a serous exudation within 
the alveoli and in the interstitial tissue of the 
lungs. 

Etiology : — Pulmonary edema appears as a 
secondary manifestation of an acute or chronic 
affection, and is usually independent of any con- 
gestion or inflammatory process. It is observed 
in certain cases at the termination of a long con- 
tinued exhaustive disease in which the heart has 
been over-worked and the weakness has resulted 
in a variation of the blood pressure. Local 
changes in the blood vessels and changes in the 
character of the blood itself are active causes at 
times; these conditions are found during the last 
stages of Bright's disease, organic diseases of the 
heart, of the cachexias and anaemias. It will be 
observed also during pneumonia, bronchitis, em- 
physema, and the infectious fevers in each of 
which its ultimate cause is always a circulatory 
one. 



EDEMA OF THE LUNGS. 167 

Pathology : — The process may be circumscribed 
or diffused; the former is usually seen in the tissue 
surrounding an inflammatory mass, while the latter 
begins at the base of the lungs and extends up- 
wards. The lung is voluminous and does not re- 
tract; it is pale or tinged red, pits on pressure, 
is heavy, and may be friable; upon section a 
pale frothy fluid flows from the cut surface and 
should there be any congestion there is a blood- 
stained fluid exudate. 

Symptoms : — The symptoms of the original dis- 
ease may for a time over-shadow those resulting 
from the edema; but dyspnea is always present 
and is often severe. The breathing is rapid, 
cyanosis is observed, and there is a cough at- 
tended with expectoration of large quantities of 
semi-mucoid fluid. Unless there is some asso- 
ciated disease the temperature is normal. The 
pulse is feeble and accelerated. The extremities 
are cold and livid. 

Physical Signs: — Inspection. This reveals a 
dyspnea which has appeared suddenly, cyanosis, 
and the signs of a general dropsy. 

Palpation: — This does not give any information 
not obtainable by inspection. 

Percussion: — Dullness is present over the lower 
portion of one or both lungs. 

Auscultation: — Vocal resonance may be slightly 
increased; the respiratory murmur is vesicular; in 
some cases it is slightly broncho-vesicular; rales 
which are fine and subcrepitant are usually heard 
both upon inspiration and expiration, in the lower 
and posterior portion of the lung. If the process 
is such as to cause a tension in the pulmonary cir- 



1 68 EDEMA OF THE LUNGS. 

culation the second pulmonic sound is accentuated. 
As the edema increases the rales are heard higher 
up in the chest; and as the fluid in the lower por- 
tion collects in greater quantities, expelling the 
air, the lung becomes solid, and flatness on per- 
cussion is present. 

Diagnosis: — The most reliable signs are the 
presence of fine crepitant rales, especially at the 
base of the lung; the incomplete dullness that is 
usually bilateral and most marked at the base of 
the lungs, and the absence of fever except when 
there is an underlying affection. 

Prognosis : — This is governed by the condition 
upon which the edema is dependent, as the edema 
is an indication that the disease is advancing to 
more serious results. When it is the result of 
renal or cardiac disease it may destroy life rapidly. 
Its onset may be gradual or rapid; it may reach 
a certain height and then recede, or it may come 
on suddenly with great dyspnea, cough, and ex- 
pectoration, and kill in a few hours. 

TreaUneni: — It should be remembered that 
edema of the lungs from v/hatever cause may 
terminatie life suddenly, usually by a cardiac fail- 
ure due to over-distension of the right heart. 
The primary causes should be sought for, as the 
prevention of the edema is the object to be at- 
tained. Should it be the kidneys that are 
at fault everything possible must be done to 
cause active elimination through the bowels and 
skin as well as through the kidneys. When it is 
the result of cardiac weakness, means must be 
adopted to strengthen the heart and assist the 
circulation. In some cases rest will be indicated, 



EDEMA OF THE LUNGS. 1 69 

in Others exercise either in the form of massage, 
resistant or gradual exercise, together with such 
remedies as will assist the circulation. In those 
cases where the attack is sudden and severe, 
threatening life at once, venesection and the with- 
drawal of from six to ten ounces of blood will 
afford great relief as will dry cupping along the 
spine and the application of turpentine stupes ap- 
plied alternately upon the front and back of the 
chest. Inhalation of oxygen has assisted some 
cases temporarily at least. Merc. dulc. or elater- 
ium given in such quantities as to keep the bowels 
active will assist in many cases. The aromatic 
spirits of ammonia will be found serviceable. 

Kali iodatum: — This remedy has the power of 
producing edema in certain individuals where the 
sputa is like soap-suds. 

Arsenicum album: — When this remedy is indi- 
cated the edema is dependent upon a derangement 
of the kidneys. The attacks are apt to be parox- 
ysmal in character, are worse before midnight, 
there is loss of breath on lying down, with anxiety, 
restlessness, and a constant thirst for small quan- 
tities of water. 

Tartarus emeticus: — There are loud, coarse rales 
with an intense dyspnea and threatened suffoca- 
tion. The bronchial tubes are filled with a serous 
fluid. 

Phosphorus: — There is great oppression of the 
chest with violent cough and expectoration of a 
mucoid material stained with blood. 

Ammonium carbonicum: — This may be of ser- 
vice in doses of from one to two grains repeated 



170 PJDEMA OF THE LUNGS. 

every ^hour, or less in cases where there is 
cyanosis with weak heart's action, drowsiness, and 
a large amount of fluid in the lungs which the 
patient cannot expectorate. 



CHAPTER XVII. 
PULMONARY FIBROSIS. 



- Synonyms : — Interstitial pneumonia, chronic or 
fibroid pneumonia, cirrhosis of the lung. 

Definition: — This is the result of a productive 
inflammation in which there has been a gradual 
increase in the connective tissues of the lung. 

Etiology: — Fibrosis is found in some degree 
as a result of nearly all disease to which the lungs 
are subject, while in chronic disseminated tubercu- 
losis it acts as a conservative process. It may re- 
sult from the development of new tissue within 
the pulmonary alveoli, or from a fibrous thickening 
of the sub-pleural, inter-alveolar, inter-lobular, 
peri-bronchial and peri-vascular connective tissue. 
Of the causes giving rise to this condition, pul- 
monary tuberculosis is the most common, espe- 
cially the chronic and fibroid forms; pneumonia, 
both the lobar and lobular type are at times fol- 
lowed by this condition as well as bronchiectasis; 
inhalations of an irritating substance are a cause 
and are considered under a special heading. 
Pleurisy is considered as a cause by many and yet it 
is doubtful if uncomplicated pleurisy produces it. 
Syphilis is the most common cause of congenital 
fibrosis, while a fibrous induration results from a 
previous gummata. Foreign bodies in the bronchi, 
aneurysm and malignant growths produce it at 
times. 



1/2 PULMONARY FIBROSIS. 

Pathology : — These changes may be confined 
to small patches, a whole lobe, or there may be 
fibrous bands scattered symmetrically through both 
lungs. The first, or broncho-pneumonic form may 
be found in any part of the lung but most fre- 
quently in the lower lobes, where it appears sec- 
ondary to measles, whooping-cough or scarlet 
fever. The parts involved are deeply pigmented 
and separated from one another by healthy or 
emphysematous tissue. Bronchiectasis and aneur- 
ysms often result from it. Microscopical examina- 
tion shows a growth of the connective tissue with- 
in the alveoli and frame-work of the lung. The 
lobar form affects a lower lobe of the lung which 
is of a greyish color, with marbled areas. It is 
solid and indurated, presenting a granular appear- 
ance. The lobe shrinks, due to a contraction of 
the newly-formed fibrous tissue. Bronchiectasis 
may occur, and later septic broncho-pneumonia or 
gangrene. In the reticular form the outer coats 
of the bronchi, arteries, and veins show a fibro- 
cellular thickening. 

Symptoms : — These vary according to the ex- 
tent of the fibrosis. In some cases where the 
process is slight there is but a modification of the 
original disease; while in the more important 
lesions as croupous, lobular pneumonia, and pleu- 
risy there is not complete recovery and a cough 
remains with an expectoration of mucus or muco- 
purulent material. At times hemoptysis is present. 
Even in non-tubercular cases there is a degree of 
dyspnea. Fever is not marked unless there is 
bronchial dilatation and a septic condition present. 
The process is chronic in character; and as the 



PULMONARY FIBROSIS. 1 73 

interference with the circulation becomes ' more 
pronounced cardiac failure follows. 

Physical Signs: — Inspection. The patient is 
emaciated, the chest wall of the affected side is 
retracted in its movements, while the healthy side 
is enlarged. The heart is displaced towards the 
diseased side. The spinal column is curved. The 
ribs are approximated on the diseased side, while 
the shoulder of the same side droops. The finger 
ends are frequently clubbed. 

Palpation: — This shows that expansion is lim- 
ited. The vocal fremitus is usually increased 
except where there is marked thickening of the 
pleura and hardening of the lung. 

Percussion: — The percussion note varies; at one 
point when over a consolidated area, it is high 
pitched, ranging from a slight dullness to flatness; 
over a bronchial dilatation or cavity it will be 
amphoric or cavernous. 

Auscultation: — The vocal resonance is increased, 
the breathing is broncho-vesicular in character, at 
times it is cavernous, expiration is prolonged, rales 
are heard which are either subcrepitant,- sonorous, 
gurgling, or sibilant. 

Diagnosis: — This is based upon the clinical 
history of the case and the evidence gained by a 
physical examination. When the process is dif- 
fused, the main question is whether it is tubercu- 
lar or not; this being determined by an examin- 
ation of the sputum. It should be differentiated 
from pleurisy with effusion, bronchiectasis, and 
malignant growth of the lung. 

Prognosis: — This is a chronic disease, and 
while it may last for many years, it always short- 



I74 PULMONARY FIBROSIS. 

ens the life of the patient; while the development 
of pneumonia always renders the prognosis grave; 
the right heart is dilated and tricuspid regurgita- 
tion may follow. 

Treatment: — As the disease is incurable, an 
attempt should be made to check its inroads upon 
the system. To accomplish this, systematic deep 
breathing, pulmonary calisthenics, a general hy- 
giene, and a favorable climate are the most ser- 
viceable. The systematic breathing should be so 
adapted as to relieve the portion of the lung 
affected. As these patients are subject to repeated 
attacks of bronchitis, often tubercular, they should 
be kept in a climate that is warm and dry 
and has an excess of sunshine. The elevation 
should not be over twelve to fifteen hundred feet, 
and it may be necessary for the patient to change 
his place of residence during the different seasons 
of the year. When syphilis is the cause of the 
fibrosis it should receive attention and the proper 
remedies be given. The right heart is liable to 
become dilated and then such remedies as the 
iodide of arsenic, strychnia, and digitalis will be 
of service. 

Where bronchiectasis is present it should be 
managed as directed under that subject. 



HYPOSTATIC HYPEREMIA. 1 75 

HYPOSTATIC HYPEREMIA* 

Synonyms: — Splenozation, hypostatic pneu- 
monia. 

Definition: — This is a feeble condition of the 
circulation that allows the blood to settle in the 
most dependent part of the lungs. 

Etiology: — The most common causes are a 
feeble heart's action, as is met with during pro- 
longed fevers, confinement in bed of those suffer- 
ing with carcinoma, tuberculosis, paralysis, or any 
disease that is attended with marked debility. 

Pathology : — The portion of the lung involved 
is of a dark color, the air vesicles being filled 
with a transuded blood and serum, and a dark 
blood flows from the cut surface. It contains but 
little air, is firm to the touch, and constitutes a 
condition termed hypostatic pneumonia. 

Symptoms: — In some cases there may be noth- 
ing to attract the attention to this process. But 
in those who are much debilitated and confined to 
bed it should be sought for. At times there is a 
slight cyanosis, and the patient sleeps with the 
mouth open. An examination of the most de- 
pendent part of the lungs shows that there is an 
increased fremitus, that dullness is appearing and 
the vesicular murmur is diminished, while if the 
process is advanced, there is bronchial breathing, 
and rales are heard. 

Diagnosis : — This is based on the history and 
symptoms as stated. 

Prognosis : — This depends upon the cause. 

Treatfnent: — As hypostatic congestion is but 
a complication arising during the progress of some 



176 HYPOSTATIC HYPEREMIA. 

of the conditions already named, its treatment 
consists in management of the primary disease, and 
the adoption of such methods as will prevent the 
development of this complication. The position of 
the patient should be changed from time to time, 
that the fluids may not be allowed to settle in 
any particular part. Attention should be given to 
the nourishment that it be sufficient and such as 
will support the heart and remove any tendency 
to asthenia. The skin should receive attention 
and the circulation assisted by massage and inunc- 
tions. The bowels should be carefully regulated, 
and at times rectal enemata of food will be bene- 
ficial. If the patient is in such a condition that 
it is possible he should be made to take sys- 
tematic, deep, full respirations. In the selection 
of the remedy the general condition of the pa- 
tient should always be the basis upon which it is 
made. 

Acidum muriaticum: — This remedy should be 
thought of in diseases of the asthenic type, where 
there is delirium and unconsciousness, with so 
great debility that the eyes are closed, the lower 
jaw hangs down, and the patient slides down in 
bed. There is paralysis of both the tongue and 
the sphincter. In fact the whole condition is one 
of intense prostration. 

Arsenicum album: — This remedy should be 
studied when there is great prostration, with rapid 
sinking of the vital forces. The anguish, restless- 
ness, and fear of death increase with the suffer- 
ing. The patient may be too weak to move him- 
self, yet there is mental restlessness. 

Rhus toxicodendron: — Where there is great 



PASSIVE HYPEREMIA. 1 77 

restlessness relieved only momentarily by move- 
ments, this remedy should be studied. 

In some cases such remedies as digitalis, strych- 
nia, strophanthus, tartar emetic and phosphorus 
may be called for. 



PASSIVE HYPEREMIA. 

Synonyms: — Brown induration; mechanical hy- 
peremia. 

Definition: — This is a chronic condition depend- 
ent upon an obstruction to the flow of blood from 
the lungs to the heart. 

Etiology: — The most frequent cause is a mitral 
stenosis, while obstruction in the pulmonary veins, 
weakness of the left ventricle, and cerebral dis- 
eases and injuries are occasional causes. Mitral 
incompetency primarily produces a general dropsy, 
while later there is a pulmonary hyperemia estab- 
lished. 

Pathology : — The lungs are enlarged, dark red 
in color, and heavier than normal, the air cells 
crepitate but little, and the blood vessels are dis- 
tended. There is a hyperplasia and induration of 
the connective tissue of the lung, while the pleura 
shows , thickening, adhesions, and pigmentation. 
The base of the lung is the first to be involved, 
the process extending gradually upwards. 

Symptoms : — Dyspnea is the most constant 
symptom. A primary accompaniment is organic 
heart disease; others usually co-existent are a cough 
with an expectoration of serum and blood, and 



178 PASSIVE HYPEREMIA. 

pigmented alveolar epithelial cells, which, together 
with those physical signs that indicate solidification 
form a group of symptoms that are characteristic. 

Diagnosis: — This is based upon the clinical 
history of the case, the presence of an organic 
heart lesion, the dyspnea, cough, expectoration, 
and physical signs. 

Prognosis : — This depends upon the cause, 
and whether it is amenable to treatment. 

Treatment : — This must be devoted to the 
relief of the primary disease. 



CHAPTER XVIII. 
PULMONARY INFARCTIOR 



Synonyfn: — Pulmonary apoplexy. 

Definition: — This is a circumscribed pulmonary 
hemorrhage. 

Etiology: — The most frequent causes are mitral 
stenosis, or incompetency; the resulting high vas- 
cular tension, therefore, causes the rupture of a 
small pulmonary vein. Embolism and thrombosis 
of the pulmonary vessels are occasional causes. 

Pathology : — It occurs most frequently in the 
lower lobes or in the lower portion of the upper 
lobes. It varies in diameter from the fraction of 
an inch to that of the whole lung, and is conical in 
shape, the apex being at the point of rupture of the 
vessel, while the base extends toward the periphery 
where it may rise above the level of the pleura, 
having well defined margins. It is dark, firm, and 
may be multiple or confluent, and can be mistaken 
for lobular pneumonia. 

Symptoms: — In those cases that are the result 
of heart disease, there may have been noticed an 
irregular heart's action for a few days before its 
appearance, during some over-exertion or excite- 
ment, with expectoration of small blood clots; un- 
easiness, and constriction of the chest, with dyspnea 
and syncope. If it is the result of a septic embol- 
ism there will be chills, hectic fever, diarrhea, and 
exhaustion. The fever ' seldom rises above ioi° F. 
Should the infarction be large, there will be in- 



l8o PULMONARY INFARCTION. 

creased fremitus, a localized dullness, bronchial 
breathing, localized friction sounds, and upon forci- 
ble percussion, a tenderness. Rales may be heard 
both of a crepitant and subcrepitant character. 
Should there be edema or emphysema present, 
their physical signs may be observed. In those 
cases where the process is septic, the sputum may 
not only be dark, due to blood, but may contain 
the contents of an abscess. There may be perfora- 
tion of the pleura. 

Diagnosis: — The expectoration of scant}^ dark 
masses of the blood is the most positive indication, 
while extreme dyspnea, the sudden appearance of 
rapid breathing, severe pain, and fear of death are 
present. 

PULMONARY INFARCTION. CATARRHAL PNEUMONIA. 

1. Symptoms appear sud- i. Symptoms appear slowly, 
denly. 

2. Expectoration contains 2. Not so marked, 
blood. 

3. Fever not marked nor of 3. Fever higher and continues 
long duration. longer. 

PULMONARY INFARCTION. CROUPOUS PNEUMONIA. 

1. Secondary to other diseases. i. Primary. 

2. The signs are circum- 2. Are more diffused, 
scribed. 

3. Fever is low. 3- Fever is high. 

Prognosis : — This is unfavorable. 

Treatment : — Rest is to be insisted upon. 
Should the pulmonary artery be plugged, death is 
usually immediate. In other cases the heart's 
action , must be maintained. To accomplish this, 
hypodermics of ether or strychnine are serviceable. 



PULMONARY INFARCTION. lOI 

When a large portion of the lung is injured, in- 
halations of oxygen are indicated. In some cases 
the mental agony is so pronounced that some such 
anodyne as morphia must be employed. The diet 
should be light and not stimulating. Alcoholic 
stimulants should be avoided. 



ABSCESS OF THE LUNG. 

Definition: — This is a circumscribed collection 
of pus within the lung. 

Etiology: — It may result from pneumonia in 
which there has been necrosis and softening of a 
considerable area of the lung; from pulmonary 
tuberculosis when a large caseous area may have 
undergone a rapid disintegration; from non-tubercu- 
lar and pulmonary embolism that have been fol- 
lowed by softening; malignant growths of surround- 
ing structures that have perforated the lung; sup- 
puration of the bronchial glands that has extended 
to the lungs; mediastinal abscesses or abscesses that 
have perforated the diaphram; or the effects of 
traumatism on the lungs. 

Pathology : — Abscess of the lung may be single 
or multiple. The former is due to pneumonia or 
traumatism. When multiple they are more apt to 
be the result of a pyemic condition, a septic broncho- 
pneumonia or the softening of an infarction. In 
some cases it assumes the form of an infiltration of 
the structures of the part, but more frequently it is 
circumscribed. The size of the abscess may vary 
from that of a walnut to that of an orange. When 



l82 ABSCESS OF THE LUNG. 

the wall of the abscess extends to the pleura em- 
pyema usually results. 

Symptoms : — The s3'mptoms of abscess of the 
lungs are not always characteristic. During the 
period of its formation, the temperature is high 
and the fever continuous. Later, the pyrexia as- 
sumes a septic type associated with rigors such as 
are observed accompanying the formation of pus 
elsewhere in the body. The sputum is yellow, 
greenish, or brownish-yellow in color; its odor is 
not as fetid as that met with in gangrene or putrid 
bronchitis. The microscope reveals fibres of elastic 
tissue in the pus. A condition of leucocytosis is 
present. The history of the case should be con- 
sidered, as abscesses in connection with pneumonia 
are most common in those who are debilitated, 
especially those addicted to the excessive use of 
alcohol. 

Physical signs : — Inspection. — Usually this re- 
veals marked emaciation with pallor, evidence of 
prostration, dyspnea, and cough. There may be 
depression of the chest, or a bulging that is most 
pronounced during coughing. 

Palpation: — During the early stages vocal fremi- 
tus is decreased, while later, if the cavity is large, 
superficial, and communicating with a bronchus it 
is increased. 

Percussion: — This outlines an area of dullness 
that may be diffused or circumscribed which later 
gives a tympanitic note as the pus disappears. 

Auscultation: — Before the escape of the pus the 
respiratory murmur is absent or feeble, or a bron- 
chial breathing may be heard over the abscess. 
When the pus has escaped there are indications of 
a cavity. 



ABSCESS OF THE LUNG. 183 

Diagnosis: — This depends upon the history and 
the demonstration of a consolidation in which a 
cavity is formed later. The sputum is copious and 
purulent, and while it may have a fetid odor, it 
has not the fetor of gangrene. It contains elastic 
fibres. The constitutional symptoms of suppuration 
are present. 

Prognosis : — If there is but a single abscess the 
prognosis is often favorable; the abscess may rup- 
ture, and healing take place. When, however, it is 
due to septic emboli and multiple abscesses result, 
the prognosis becomes grave. 

Treatment : — When it is known that such a 
process is developing, everything possible should be 
done to harbor the strength of the patient that 
he may resist so far as possible the inroads of 
'the disease. The diet must be such as is easily 
digested and highly nutritious. In some cases 
alcoholic stimulants will be of benefit. When it is 
possible to demonstrate that an abscess exists near 
the surface it should be opened and drained. The 
questions to be considered before undertaking such 
an operation are the general condition of the patient, 
the primary disease, the site of the abscess, whether 
it is single or multiple, and whether it is possible 
to secure free drainage. When the abscess is the 
result of a pyemic condition, an operation will be 
of service. 

Inhalations of creosote may be of some service. 
When there is a cough and expectoration, no ano- 
dyne should be used as it will stop the removal of 
the purulent secretions. Such remedies should be 
employed as are known to control the suppurative 
process, as balsam of peru, silicea, hepar sulphur, 



184 ABSCESS OF THE I.UNG. 

arsenicum, arseniate of quinine, and china. For a 
description of the operation for pulmonary abscess 
the reader is referred to a text book on surgery. 



GANGRENE OF THE LUNGS. 

Definition: — This is a necrosis and decomposi- 
tion of the lung tissue. It is usually secondary to 
an inflammatory condition, and may be diffused or 
circumscribed. 

Etiology: — It is dependent upon the action of 
putrefactive bacteria in a necrotic area of the lung 
tissue. They may reach the lung through the 
bronchi, blood vessels, or from an adjacent organ. 
It is found at times as a termination of pneumonia, 
especially in those who are alcoholic or are suffer- 
ing from nephritis, diabetes, lack of nutrition or 
senilit}^ The pneumonia that accompanies influenza, 
and the lobar pneumonia that is secondary to the 
infectious diseases may terminate in gangrene. At 
times foreign bodies by lodging in the bronchus, or 
new formations by pressing upon the bronchus, may 
cause a congestion and pneumonic process that is 
later followed by a secondary infection and gan- 
grene. In the diabetic, inflammation of the lung is 
prone to terminate in gangrene. 

Pathology: — This process is most frequently 
located in the lower lobes and superficial parts of 
the right lung, but it may be observed at any 
point. It may be circumscribed or diffused, and 
may vary in size from the third of an inch to the 
whole lung. There may be several necrotic points. 
These points may be soft and of a brownish color; 



GANGRENE OF THE LUNGS. 185 

in time the foci are separated from the healthy tis- 
sue and an irregular cavity results that is left in a 
suppurating condition. The bronchi are the last to 
give way to the necrotic process, and until they do 
there is no expectoration of the putrid material. 
This discharge may work into the pleural cavity 
and infectious pleurisy result, while at times there 
is a perforation of the chest wall. In the few cases 
where the process is arrested a connective tissue 
development takes place that surrounds the necrotic 
focus. 

Symptoms: — Preceding the symptoms of gan- 
grene there is usually a history of some form of 
pulmonary disease. There is a moderate degree of 
fever, and an expectoration that is brownish, thin, 
abundant, and has a most marked gangrenous odor. 
If collected in a vessel it will show three layers; 
the upper of frothy material, a middle layer that 
is thin and watery, and a lower layer that is mostly 
purulent and contains greenish shreds. Under the 
•microscope it is seen to contain pieces of lung ele- 
ments, blood and other debris. To one who has 
attended one of these cases, the pronounced fetor 
of the breath and sputum is characteristic. 

Physical signs : — Inspection. The patient shows 
the effect of the septic condition. Dyspnea is pres- 
ent in proportion to the amount of lung involved; 
during the early stages the chest may not show 
any change, but later if recovery takes place there 
is depression. A cough is present, which in the 
diffused form is constant while in the locahzed 
variety it is but occasional. 

Palpation : — This does not convey anything 
definite, as vocal fremitus may be normal, ab- 
sent, or increased. 



l86 GANGRENE OF THE LUNGS. 

Percussion: — Early in the history of the case 
there is dullness, or possibly flatness over the gan- 
grenous area, while later as cavities form there is 
*' cracked pot" resonance. 

Auscultation: — This usually reveals moist rales; 
while over the gangrenous area the respiratory 
murmur may be absent, or the breathing ma}^ be 
bronchial and faint, while later it is cavernous. 

Diagnosis : — In the majority of cases gangrene is 
easy to recognize by the odor of the breath, the 
sputum, and the presence of broken down lung 
tissue and elastic fibres. With these there are the 
usual symptoms that accompany such conditions. 
It should be remembered that pyrexia may be 
absent in those cases where there is extreme pros- 
tration. This condition should be differentiated 
from bronchiectasis, pulmonary abscess, putrid 
bronchitis, and emphysema that has ruptured in the 
lung. 

Prognosis : — This is usually unfavorable, the end 
coming within two weeks. In some cases a more 
chronic course is taken; in a few cases the gan- 
grenous area is separated and expectorated, and re- 
covery takes place. 

Treatment: — The treatment is not satisfactory. 
The indications are to maintain the strength of the 
patient, reduce the fetor of the sputum, and to 
drain the cavity. The patient should be kept in 
bed, and nourishment administered at short intervals. 
This should be light, fluid, and highly nutritious^ 
such as broths, milk, etc. In these cases stimu- 
lants will be of service, good brandy or whiskey 
being preferable. To allay the fetor, medicated 
vapor should be continually inhaled which may 



GANGRENE OF THE LUNGS. 1 87 

be accomplished by using a Robinson inhaler that 
has been saturated with a solution of creosote and 
menthol ( 20 per cent ) or equal parts of beech-wood 
creosote, chloroform and alcohol. Iodine, carbolic 
acid, bromine, thymol, myrtol or eucalyptol may 
also be used. Subcutaneous injections, 15 grains 
per da3% of sterilized oil of guaiacol has diminished 
the fetor in many cases. When the spot is near 
the surface surgical interference is permissible. 

Internal medicine may not produce as marked 
results as might be hoped for; yet in the more 
rapid cases, arsenicum album or china may be of 
service, while in those cases where the course of 
the disease is slower, camphor 3X, carbo vegetabilis 
or creosote may be indicated. When there is 
hemorrhage accompanied by collapse, rapid prostra- 
tion, coldness of the extremities, exhausting diarrhea 
with vertigo and delirium, secale cornutum is indi- 
cated. Sodium hyposulphite in solution may be in- 
haled from a vaporizer. 



CHAPTER XIX. 
PNEUMOKONIOSIS. 



Synonym : — Pneumoconious. 

Definition: — This is a group of diseases that 
result from the mechanical effects of dust, in their 
earlier stages at least. 

Etiology: — The conditions favorable to their 
development are a dry, dusty atmosphere and the 
absence of a proper ventilation. While they will 
develop in any dusty atmosphere, they are more 
common among those working with coal, iron, and 
minerals used for grinding. 

Anthracosis: — The lungs of those working in 
coal mines show pigmentation and develop what is 
known as coal miner's lung, or coal miner's phthisis. 

Siderosis: — This term is employed in speaking 
of the disease when it is due to the inhalation of 
particles of steel, as in knife grinders and others 
who inhale particles of steel and iron. This is 
spoken of as knife grinder's phthisis. 

Calicosis: — This term is used in speaking of the 
inhalations of particles of mineral as in making mill 
stones and finely ground minerals. 

Miller's phthisis is used in speaking of the dis- 
ease that results from grinding cereals. There are 
other occupations that are attended with a like result, 
but in a less degree, as flax disease, and that present 
in workers in cotton, tobacco, hemp, chaff cutters, 
etc. 

Pathology : — The most marked change is in the 
connective tissue surrounding the lymphatics, where 



PNEUMOKONIOSIS. 1 89 



a proliferation takes place, that in the early stages 
is more cellular, but later is fibrous. This leads to 
a compression of the blood vessels and encroaches 
upon, the alveolar spaces; this may render the part 
impervious to air, and establish a chronic interstitial 
pneumonia. There is also a catarrhal inflammation 
of the bronchial mucous membrane due to local 
irritation which in time becomes chronic. The 
peribronchial tissue is thickened and results in bron- 
chiectasis of the sacculated variety. As a result of 
the cough that is present, emphysema develops. 

In the later stages many times a softening of 
the newly formed connective tissue takes place with 
the formation of cavities. This is in the nature of 
a necrosis, and is often associated with the tubercle 
bacilli, which were not present during the early 
stages. 

Symptoms: — A cough is one of the earliest 
symptoms in a person whose work is in a dusty 
atmosphere. In some cases dyspnea may precede 
the cough. As the result of the cough, emphysema 
is developed, which is accompanied with a d3^spnea 
that is paroxysmal and may assume the asthmatic 
type at times. In cotton workers, paroxysms of 
sneezing may be the first symptoms complained of. 
So long as the disease is principally limited to the 
bronchial tubes the symptoms are those of a bron- 
chitis, with a sputum that is at first mucoid, but 
gradually becomes more profuse and purulent as 
the disease becomes chronic. The color of the 
sputum varies with the employment. All the symp- 
toms are worse during the winter and spring. The 
disease ma}^ be present for many years with but a 
slight degree of emaciation; but as softening appears 



IpO PNEUMOKONIOSIS. 



the temperature assumes the remittent type; emacia- 
tion becomes rapid, there are night sweats, diar- 
rhea, and dropsy; all symptoms now point to an 
active tuberculosis. 

Physical signs : — These vary with the stage 
of the disease and the amount of emphysema pres- 
ent, and may mask any consolidation that exists, as 
well as the fine rales; should there be no emphy- 
sema, any consolidation, softening or cavities may 
be recognized by the usual signs. 

Diagnosis: — This is arrived at by a considera- 
tion of the occupation, the failing health, the sputa, 
and the other symptoms of the disease. 

Prognosis: — This depends upon the stage of 
the disease, and the early possible change of occu- 
pation to a more healthy one. 

Treatment: — If the individual will abandon his 
unhealth}^ task in the early stage of the disease, he 
may recover; if he does not, it will kill him shortly 
after middle life. Something may be done in the 
way of using inhalers, and thus preventing the in- 
halation of the dust; also by compelling companies 
to provide better ventilation in their shops. The 
nutrition should be maintained; there should be 
much time spent in the open air, that the general 
health may be improved. The conditions that 
result, as emphysema, bronchitis, etc., must receive 
the treatment indicated. 



PULMONARY ACTINOMYCOSIS. I9I 

PULMONARY ACTINOMYCOSIS. 

Definition: — This is a chronic infectious disease 
caused by the ra}^ fungus, the actinomycoses. 

Etiology : — The fungus gains entrance into the 
system either through the alimentary or respiratory 
tract. 

Pathology: — The lesions are most frequently 
unilateral, and are found in the form of chronic 
bronchitis; miliary lesions resembling miliary tuber- 
culosis, and destructive lesions that in some cases 
resemble broncho-pneumonia; in others fibrosis, and 
in still others pulmonary abscesses. In those cases 
where the chest wall is involved, it is enlarged; 
the intercostal spaces are obliterated, the soft tis- 
sues are discolored and edematous, while the skin 
is mottled and abscesses form, which discharge 
a little pus from the opening that is surrounded by 
fungoid masses of red and yellow granulation tissue. 
The same process often involves other parts of the 
body, and necrosis of the bones is met with. 

Symptoms : — The disease appears and pursues a 
gradual course; there is a cough, which is attended 
with but little expectoration. The temperature is 
elevated, the fever assuming a hectic type. There 
is a general weakness and a gradual loss of flesh; 
the patient becomes pale and anemic; the expecto- 
ration becomes profuse, and is muco-purulent or 
fetid in character. As the chest is involved the 
contour of the side changes, the soft tissue becomes 
swollen and inflamed, and abscesses form. The pus 
is discharged through sinuses that are surrounded 
by granulation tissue. In some cases it will require 
close observation to distinguish it from typhoid 



192 PULMONARY ACTINOMYCOSIS. 

fever in the early stage. The disease is pro- 
gressive, lasting about one year. Recovery seldom 
takes place and death is often preceded by a gen- 
eral septic condition. 

Physical signs : — Inspection. This shows the pa- 
tient to be anemic and emaciated, and there are 
often changes in the contour of the side. 

Palpation: — This does not add much information 
to that gained by inspection. 

Percussion: — This often shows dullness, and 
many symptoms that simulate pleural effusion. 

Auscultation : — This may not reveal in some 
anything that is definite, while in others there are 
symptoms that indicate bronchitis. 

Diagnosis : — This is dependent upon the S3^mp- 
toms as outlined, and the presence of the actinomy- 
coses as revealed by the microscope. 

Prognosis: — The course is chronic; and while 
recoveries take place, they .are very rare. Death 
usuall}^ results from pyemia, amyloid degeneration, 
and asthenia. 

Treatment : — The strength of the patient should 
be supported in every possible way. The iodide of 
potassium has been employed both by the mouth 
and hypodermatically, but the results are not flat- 
tering. If the disease is yet local, surgical proced- 
ure may be of service. 



HYDATIDS OF THE LUNGS, I93 

HYDATIDS OF THE LUNGS. 

Synonym : — Echinococcus. 

Definition: — This is due to the presence in the 
lungs of the larvae of the tenia echinococcus. 

Etiology: — The ova may gain entrance to the 
body either through the respiratory tract or through 
the alimentary canal and thence by the vascular 
system to the lungs. . It is more frequently found 
in the lungs than in the pleurae. 

Pathology : — As the embr3^o reaches its destina- 
tion, it loses its booklets, and becomes transformed 
into a cyst, which contains a clear fluid and the 
booklets. Its external wall is thick, elastic, and 
transparent, while the internal is granular. As the 
cyst develops, it presses upon the surrounding tis- 
sue, leading to inflammation, gangrene, and at times 
cavities. The cyst may rupture and discharge into 
a bronchus, the pleura or the pericardium. Gan- 
grene and pneumonic changes in the lung may lead 
to a death of the cyst, which is followed by sup- 
puration, when it becomes an abscess and may 
discharge in any direction. These cysts are usuall}' 
single and seldom multilocular; while both lungs 
may be involved, the right one is more frequently 
affected than the left, and the lower lobe more fre- 
quently than the upper. 

Symptoms: — A small cyst may give rise to no 
symptoms that are definite, but in many cases 
there is a dry, hacking, paroxysmal cough with a 
mucoid expectoration, and slight hemoptysis during 
the early stage, which later is more profuse. Un- 
less there is inflammation, there is but little if any 
fever. There is a slight dyspnea, but no pain is 



IQ4 HYDATIDS OF THE LUNGS. 

complained of unless the pleura is involved. There 
is some constriction about the chest. Should the 
cyst be a large one, the chest expansion is dimin- 
ished, as well as the respiratory murmur. 

Physical signs : — These differ with the location 
of the C3^st. If it is near the surface there is a de- 
fective expansion. The vocal fremitus is diminished, 
there is dullness or tympanitic note over the site of 
the cyst. Should the cyst be near the surface the 
so-called hydatid thrill may be felt. Subcrepitant 
rales, the result of edema and congestion of the 
lung tissue, may be heard. 

Diagnosis: — This is dependent upon the pres- 
ence of scolices, pieces of the membrane, and hook- 
lets in the sputum. 

Prognosis : — This affection is always attended 
with danger, and especially is this true if it is 
secondary to involvement of the liver. 

Treatment : — The medical treatment is not satis- 
factory, the symptoms being met as they arise. 
If the growth is situated near the periphery of the 
lung, an operation should be considered. Paracen- 
tisis, while it has resulted in a few cures is 
attended with danger, as the fluid may escape into 
the bronchi and prove fatal. The surgical proced- 
ure adopted for pulmonary abscesses -or other lung 
cavities is most serviceable. The important ques- 
tion is whether to simply drain the cavity, or to 
remove the ectocyst (outer wall) as well. In the 
later stages when the condition is one resembling 
an abscess, the diet must be nutritious and support- 
ing; and such remedies employed as will contribute 
to this end. 



CHAPTER XX. 
PULMONARY MYCOSIS* 



Synojiy?n : — Pneumomycosis. 

Definition: — This is a disease of the lungs due 
to the presence of a fungus. 

Etiology: — The principal forms of this disease 
are those due to the presence of the aspergillus 
fumegatus, also the saricinal; and some of the 
mucosinal. The disease has been observed most 
frequently in those who handle grain, flour, or 
meal that has been infected with the spore of the 
aspergillus. Hair combers, seedmen, and millers 
suffer from it. 

Pathology : — The changes wrought in the lungs 
are very similar to those of tuberculosis. 

Symptoms: — In many cases they closely resem- 
ble those due to tuberculosis. There is a sense of 
fatigue with loss of strength which is followed by 
dyspepsia, loss of appetite and emaciation. A 
cough appears, which at first is dry and paroxys- 
mal, but later an expectoration appears that is 
frothy, and then green and purulent, and may be 
blood-streaked. There is a rise in the evening 
temperature and night sweats are occasionally 
present. A dry pleurisy develops in some cases. 
As the disease advances weakness increases; there 
are severe hemorrhages, and edema of the legs 
appears. 

Physical signs: — During the early stages the 
physical signs are such as indicate bronchitis, 



jg6 PULMONARY MYCOSIS. 

while later there is consolidation, generally at the 
apex of the lung. 

Diagnosis : — This is dependent upon the nature 
of the infection which can only be recognized by 
the discovery of the small, rounded, white or yel- 
lowish white, body in the expectoration. 

Prognasis : — Should the disease be complicated 
by tuberculosis the prognosis becomes unfavorable. 
At times there will be periods of improvement 
and in some cases there is an arrest of the disease, 
accompanied by a fibrosis of the lung. Cases 
have been known to last from six to eight years. 

Treatment : — This consists in removing the 
patient to a locality where the air is free from 
organic impurities; in developing the resisting 
powers, in supplying an abundance of food, and 
in enforcing rest during the fever. The cough, 
hemoptysis, and asthmatic attacks must be man- 
aged as outlined elsewhere. 

PULMONARY COMPLICATIONS OF ACUTE DISEASES. 

Whooping cough: — The most important lesions 
associated with whooping cough are broncho-pneu- 
monia, atalectasis, bronchial dilatation, emphysema, 
pneumothorax, and enlargement of the bronchial 
gland. 

Injluenza: — The pulmonary complications of 
influenza are of importance as they are nearly 
always present in fatal cases. The complications 
most frequently met with are tracheo-bronchitis, 
broncho-pneumonia, and lobar pneumonia. The 
symptoms and physical signs of the complication 
are now added to the original disease. Those 
who have suffered from pulmonary complications 



PULMONARY MYCOSIS. I97 

in previous attacks should be carefully protected, 
and attention be devoted to the lung, that the 
complications may be avoided if possible. 

PULMONARY ANEMIA. 

The apices of the lungs are normally anemic. 
The causes giving rise to this condition are 
emphysema, hemorrhages, embolism, thrombosis, 
stenosis of the pulmonary artery, and new forma- 
tions. 

The affected portion is paler than normal and 
contains less blood. 

The symptoms are such as would occur from a 
deficiency of blood passing through the lungs, and 
the resulting lack of oxygenation; such as quick- 
ening of the respiration, restlessness, anxiety, in- 
creased heart action, and ineffectual attempts to 
draw a long breath. The prognosis and treatment 
must depend upon the cause. 

TUMORS OF THE LUNGS. 

These may be primary or secondary; the latter 
being the most frequently met with; the former 
being rare. When primary they may be of the 
type of epithelioma, encephaloid, scirrhus, or sar- 
coma. When secondary they may be encephaloid, 
scirrhus, epithelioma, colloid, melano-sarcoma, or 
osteoma. 

Etiology: — These are most frequently met with 
between forty and sixty years of age. The sexes 
are about equally attacked with the primary forms, 
but the secondary are more frequent among 
females. 

Pathology : — Primary sarcoma and carcinoma 
are usually found in but one lung and involve the 



198 PULMONARY MYCOSIS. 

greater part of it, most frequently the right lung; 
while secondary growths are more frequently dis- 
tributed throughout both lungs. The primary 
growth may appear as a circumscribed tumor or 
as an infiltration; all traces of the lung are de- 
stroyed in some cases. The mass may be soft 
and fleshy, or hard and solid. Sarcomata develops 
masses, also nodules throughout the lung. In 
some cases when there is a dense infiltration the 
lungs may be enlarged while in other cases there 
is retraction or softening, and collections of pus 
may occur. 

Symptoms: — There are no definite and constant 
symptoms connected with these cases. If the 
pleura is involved the patient complains of severe 
pain. Should the growth press upon the trachea 
a troublesome paroxysmal dyspnea is often pres- 
ent. A dry, painful cough with mucoid, and later 
a currant jelly expectoration may be present. Pas- 
sive congestion of the face and upper extremities 
may occur from pressure. 

Physical signs: — There may be some bulging 
of the side; or a retraction, due to collapse of a 
portion of the lung, which is the result of bron- 
chial obstruction may result. The vocal fremitus 
may be increased, diminished, or absent. 

Percussion may not show dullness, while the 
breathing may be bronchial in character. 

Diagnosis : — This is easy in secondary growths. 
There is the progressive emaciation, metastatic 
involvement of the cervical glands, dark expecto- 
ration, and the physical signs. 

Prognosis : — Unfavorable. 



PULMONARY MYCOSIS. I99 

Treahnent : — This is unsatisfactory. In some 
cases surgical means may be considered. 

SYPHILIS OF THE LUNGS. 

This may be the result of congenital or ac- 
quired syphilis. When congenital its manifesta- 
tions are either circumscribed or diffused; the for- 
mer is termed gumma, while the term pneumonic is 
applied to the latter. 

Gumma is of rare occurrence in congenital 
syphilis, and when present is similar to that found 
in acquired syphilis. 

The pneumonic variety appears under two 
forms, known as "white pneumonia" and " inter- 
stititial pneumonia." 

White pneumonia is observed in the lungs of 
those who are still-born, or have survived 
but a short time. In all these cases there are 
other evidences of congenital syphilis. The 
changes may be confined to a lobe or a part of a 
lobe; or the whole of one or both lungs may be 
involved. In still-born children the affected part 
is bloodless and airless. If the child has lived 
for a few days there is air in the lung, which is 
increased in size, so that its surface takes the 
imprints of the ribs. Upon section the lung is 
smooth, solid, somewhat shining, and of a Vv^hite, 
yellow, or greyish white color. 

Interstitial pneumonia is more frequently met 
with than the former named variety in inherited 
syphilis, and yet the two processes are frequently 
associated. The lung is large, hard, and of a 
pale, greyish reddish tinge. The changes may be 
confined to a single lobe, or be diffused through- 



200 PULMONARY MYCOSIS. 

out the lung. The tissue presents a coarse appear- 
ance, and under the microscope shows a small 
celled infiltration of, and increase in, the intra- 
alveolar connective tissue, as well as the inter- 
lobular connective tissue, while the blood vessels 
are dilated and tortuous. 

Pathology: — During the secondary stages of 
syphilis, and at times during the later stages of 
the period of incubation, bronchial catarrh may 
appear. The pulmonary lesions of acquired syph- 
ilis are more marked during the late tertiary 
stages of the disease, when they may appear in 
the form of gummata, broncho-pneumonia or fibroid 
induration. The gumma may be single or 
multiple, and may vary in size, some being as 
large as a small hen's ^gg. While found at any 
point in the lung, they are most common at the 
root. 

Fibroid induration presents itself in the form 
of a thickening extending from the hilus about the 
bronchi and blood vessels, either as localized fibroid 
masses, or as diffused changes through the 
lung. The lymphatic glands are enlarged and 
softened. 

Symptoms: — During the secondary stage the 
catarrhal indications are generally diffused, while 
in the tertiary stages, due to the formation of 
gumma in the main bronchi, they become more 
localized. Should a stenosis take place during the 
early stages, the bronchial breathing is but 
slightly interfered with, but as the stenosis be- 
comes more marked the breath sounds become 
more feeble and ultimately disappear, when the 
air can no longer pass the obstruction. Should 



PULMONARY MYCOSIS. 20I 

bronchiectasis be formed behind the stenosis, there 
will be a cough, and a profuse, purulent, fetid ex- 
pectoration, accompanied by a moderate fever and 
emaciation. 

Cough is present in all of these cases which in 
their early stages are dependent upon changes in 
the larynx, trachea and bronchi, while later it 
results from changes within the lung. Dyspnea is 
present in proportion to the extent of the pulmo- 
nary lesion. It has a tendency to become parox- 
ysmal. Hemoptysis is not common but may be a 
severe complication at times. Expectoration is 
common in advanced cases; the sputum, while it is 
profuse, offensive and purulent, does not contain 
tubercle bacilli. Pain, while present, is not 
usually severe, and the emaciation is not as great 
as that met with in tuberculosis. Night sweats 
are often present, and the general symptoms may 
simulate tuberculosis. 

Physical signs: — Inspection. This may show 
many indications of syphilis, and if the case is 
advanced there is emaciation. 

Palpation: — This will depend upon the form of 
the lesion present. 

Percussion: — This will reveal dullness in propor- 
tion to the lesion. 

Auscultation: — This will show the changes as 
found in the various lesions. 

Diagnosis: — This is based upon the presence 
of constitutional syphilis, and the recognition of 
the pulmonary lesion. 

Prognosis: — Pulmonary lesions that are exten- 
sive and of a severe type are a grave complica- 



202 PULMONARY MYCOSIS. 

tion of syphilis; death may result from an inter- 
ference with the breathing and exhaustion. 

Treatjuent : — The general health should be im- 
proved and the nutrition maintained so far as pos- 
sible. Patients known to have syphilis should be 
continually watched, and treated until the last ves- 
tige of the disease is removed, if possible. 

Natrum iodatum: — It is during the tertiary 
stage that this remedy is indicated. There are 
bone pains which are gnawing in character; 
there is throbbing and burning in the nasal and 
frontal bones; the discharges are excoriating. 
There are many symptoms indicating pulmonary 
phthisis which are due to syphilitic ulceration. 
It should be employed in increasing doses begin- 
ning with five drops of the saturated solution and 
gradually increasing until fifteen or twenty drops 
are being taken after each meal. 

Mercury: — Some one of the preparations of 
mercury may be indicated when there is the ulcer- 
ation, fetid breath and other symptoms indicating 
this drug. 

Acidum Nitricum: — When mercury has been 
abused. There is bleeding from the lungs and 
ulcerated points, with pains that are burning and 
sticking in character. 

The other remedies that may be a positive 
benefit are phytolacca, kali bichromicum and sarsa- 
parilla. 



( 



CHAPTER XXI. 
PLEURISY^ 



Definition: — This is an inflammation of the 
pleural membrane. 

Varieties : — It may be acute or chronic, 
primary or secondary, localized or general, fib- 
rinous, sero-fibrinous, or purulent. 

FIBRINOUS PLEURISY. 

Synonyms : — Dry, acute, plastic pleurisy. 

Etiology: — Exposure to cold and wet, by low- 
ering the resisting power of the subject, is a 
frequent cause. It is observed more frequently 
among men than women, and during the winter 
than summer season. Traumatism is an occasional 
cause. It may arise as the result of pneumonia, 
pulmonary abscess, gangrene, hepatitis, acute 
articular rheumatism, chronic pulmonary tubercu- 
losis, Bright's disease, or from inflammation of the 
membrane of surrounding cavities. 

Pathology : — The first change is a congestion 
of the surface of the pleura, when it loses its 
lustre and becomes rough and dry. This is fol- 
lowed by an exudate of a fibrinous character, 
varying in thickness and extent of the surface cov- 
ered. By the fifth day capillaries have developed 
in the exudate which becomes organized into 
fibrous tissue. The surfaces do not regain their 
normal condition following the inflammation. In 
some cases the opposite pleural surfaces become 



204 PLEURISY. 



agglutinated, forming adhesions which bind the 
surfaces together. 

Symptoms: — Pain in the cide is usually the 
first and most constant symptom. Accompanying 
or even preceding the pain there is a chill or chil- 
liness; in some cases this is not marked. The 
pain in well developed cases is sharp and piercing, 
beginning at about the middle of inspiration and 
ceasing with the beginning of expiration. In some 
cases, especially in pleurisy of the apex and that 
accompanying pneumonia, the pain may be con- 
stant. The location of the pain will vary accord- 
ing to the portion of the pleura involved. It is 
usually felt in the axillary region, or below the 
nipple, but when the inflammation is at the apex 
of the lung it will be felt at the top of the 
shoulder or under the upper portion of the scapula. 

When the diaphragm is involved, the pain is 
felt low in the back or in the abdomen, and is 
increased by pressure over the insertion of the 
diaphragm at the tenth rib. The pain is made 
worse by coughing and deep breathing. The 
patient assumes a position that protects the side 
most during motion. The face has a look of 
anxiety. The temperature is not high, usually 
from lOO^F. to 102° F.; it may decline to normal 
after a few days and remain there during the 
course of the disease. The pulse is quickened, 
small, and may be irregular. The cough is dry, 
hacking and painful. There is but little or no 
expectoration, and the patient resists coughing. 

The respirations are slightly increased in fre- 
quency and are jerky. After three or four days 
the pain subsides leaving a feeling of soreness. 



PLEURISY. 205 



The disease has a tendency to recur, or it may 
become chronic. 

Physical signs: — Inspection. The patient is 
usually found in a position that restricts the move- 
ments of the diseased side. The respirations are 
increased in frequency and shallow. There is a 
limited movement of the affected side while the 
movements of the sound side are increased. 

Palpation: — Occasionally a friction fremitus is 
to be felt upon the affected side where deep pres- 
sure gives tenderness or pain. This is most 
marked at the tenth rib in cases of diaphragmatic 
pleurisy. 

Percussion: — This does not give any informa- 
tion apart from the tenderness. 

Auscultation:— This gives the definite sign of 
this form of pleurisy — the friction sounds, which 
may be grazing, rubbing, or grating in character. 
They are heard both during inspiration and expi- 
ration, but most marked during the former. They 
may be increased by slight pressure with the 
stethoscope. The vesicular murmur is diminished 
on the affected side, owing to the restrained move- 
ments of the parts. 

Diagnosis : — This is based upon the slight fever, 
the character and location of the pain, and the 
friction sounds as revealed by auscultation. 

Pleurisy may be mistaken for intercostal neu- 
ralgia. 

PLEURISY. INTERCOSTAL NEURALGIA. 

The pain is diffused. Is localized. 

There is a slight fever. No fever. 

Cough is present. No cough. 

Friction sounds are heard. No friction sounds. 

No herpes. Herpes may be present. 



206 PLEURISY. 



Prognosis: — Most of these cases recover after 
a period varying from a few days to two or three 
weeks. One attack predisposes to subsequent 
attacks, and as a result there is thickening of the 
pleura, intra-pleural adhesions, and interstitial 
pneumonia. 

Treatment: — The first demand of the patient is 
to be relieved of the pain. This can usually be 
accomplished by the application of heat to the 
side in the form of hot poultices, a large blanket 
wrung out of hot water, or a hot water bottle, and 
at times a mustard plaster (made by stirring 
mustard into boiling castor oil until a paste is 
formed) may be applied, and left for twelve or 
fourteen hours; if made properly it will not blister. 
In some cases the application of strips of adhesive 
plaster which will pass from the spine to the 
sternum, and drawn tightly, will be sufficient; or a 
flannel bandage may be applied. The patient 
should remain in bed, and be allowed to choose 
the position that gives him most ease. 

Attention should be given to the bowels, that 
the movements are sufficient and regular. The 
diet should be light and nutritious, but not con- 
tain too much fluid. As convalescence appears 
the patient should practice deep breathing that 
adhesions may be avoided as far as possible. In 
those cases where pain continues in the side when 
all other signs of trouble have disappeared, the 
application of a constant current over the seat of 
the pleurisy will bring relief. 

Bryonia: — This remedy may be indicated at 
any time during the process of the disease, but 
more especially after the stage of exudation has 



i 



I 



PLEURISY. 207 



appeared. The respirations are short and rapid. 
There are severe stitching pains which are greatly 
aggravated by breathing, or any form of motion. 
The patient has a desire to support the affected 
side, so that its motion is Hmited; he also chooses 
that side to lie upon. The tongue is coated white, 
there is thirst for large quantities of water at long 
intervals, and the bowels are constipated. 

Scilla: — This remedy produces stitches in the 
sides of the chest when coughing and during in- 
spiration; this is so marked in some cases that 
the patient cannot get his breath. The cough is 
dry, hacking, and irritating in the morning when 
it is attended with the stitching pains; at times 
there is a free expectoration; while it affects both 
sides, its action is most pronounced upon the left. 
The paroxysm of coughing is closed with a sneeze 
and an involuntary urination. 

Kali carbonicum: — This remedy produces stitch- 
ing pains, that are most marked upon the left 
side, and are accompanied with violent palpitation 
of the heart; the cough is dry, and there is pain 
of a stitching character in the back and nape of 
the neck. All the symptoms are aggravated at 3 
a. m. This remedy is to be distinguished from 
bryonia by being worse from rest and from lying 
on the affected side, which is just the opposite of 
bryonia. 

Sabadilla: — When bryonia has not controlled 
the stitching pains, this drug is to be studied, for 
it produces stitches and pains in the side, most 
marked when coughing, The patient is weak and 
feels as though paralyzed, and complains much of 
a sensation of coldness that is broken at times by 
flashes of heat. 



208 PLEURISY. 



Aconitum: — Should the physician be called 
early in the history of the case, this remedy may 
be indicated by the chill, with high fever, anxiety, 
and restlessness, The physical signs show that 
exudation has not yet taken place. 



i 



CHAPTER XXII. 
SERO-FIBRINOUS PLEURISY. 



Definition: — This is an inflammation of the 
pleura in which a sero-fibrinous effusion is poured 
into the pleural space. 

Etiology : — Any of the causes enumerated under 
the head of acute plastic pleurisy may produce 
this variety. Pneumonia, rheumatism, Bright's 
disease, or inflammation of the pericardium and 
mediastinum, may be accompanied by sero-fibrinous 
pleurisy. Some of these cases appear to be idio- 
pathic, but a more careful examination shows that 
they are due to micro-organisms, of which the 
tubercle bacillus is the most frequent. 

Pathology: — During the early stages, the 
changes are similar to those met with in the 
plastic variety. In the sero-fibrinous variety, the 
proportion of serum and fibrin varies widely. The 
fibrin may be upon the surface of the pleura or 
in the serum. It may be scanty or abundant. 
The effusion is usually of a light yellow color 
with a greenish tinge, but may be clear, slightly 
turbid, lemon yellow, dark brown, or red (due to 
blood). It is alkaline in reaction, and has a spe- 
cific gravity of from 1005 to 1035. It is albumin- 
ous and contains leucocytes, large cells, red blood 
corpuscles, urea, uric acid, sugar, cholesterine, leu- 
cine and tyrosin. In some cases, in connection 
with cancer, Bright's disease, cirrhosis of the liver, 
and tuberculosis, the effusion is hemorrhagic. 



2IO SERO-FIBRINOUS PLEURISY. 

The quantity of effusion varies from a few 
ounces to several pints. When this quantity is 
small, it is found in the most dependent part of 
the pleural cavity. It may be at a higher point, held 
there by adhesions. In some cases it will be 
found that there are different cavities separated by 
adhesion, and while the contents of one are puru- 
lent, others may be serous. 

The various organs are displaced toward the 
sound aide in proportion to the amount of effusion 
present, whether there are bands restraining this 
displacement or not. When the pleural sac is 
half filled, the fluid begins to compress the lung. 
As the effusion increases, the compression becomes 
more marked, until, when the effusion is large, it 
may press the lung upward and backward toward 
the vertebral column, where it becomes a small, 
bloodless, airless mass. . 

Symptoms: — In some cases there is a general 
malaise complained of for several days before the 
onset. This may be quite pronounced, and from 
the loss of appetite, weakness, palpitation of the 
heart and breathlessness, typhoid fever may be 
suspected, until a careful physical examination is 
made. In other cases the disease is ushered in 
with a chill which is followed by fever and a 
severe pain in the region of the nipple or axilla. 
This is made worse by coughing, and deep breath- 
ing. In some cases there is no pain. Dyspnea is 
present in all cases when the effusion develops 
rapidly, while in those cases where it has appeared 
slowly there may be no dyspnea present even 
when the lung is completely compressed, except 
upon exertion. 




DISPLACEMENT OF THE VISCERA DUE TO PLEURITIC EFFUSION 
ON THE LEFT SIDE, (adapted from bury.) 



212 SERO-FIBRINOUS PLEURISY. 

The patient usually takes a position upon the 
back, indining slightly to the affected- side. The 
temperature may not be above 102° F., and in 
some cases fever is absent. The pulse is quickened 
but not rapid. 

Physical signs: — These vary with the amount 
of effusion present. When this reaches but to the 
fifth rib anteriorly the following signs are present. 

Inspection: — The patient occupies a position 
upon the back or side. The respiratory movements 
on the affected side are limited, while the respira- 
tions are increased in frequency. 

Palpation: — This confirms inspection, and shows 
the vocal fremitus to be decreased over the effu- 
sion. 

Percussion: — This outlines a dullness, that is 
first noticed in the infra-scapular and infra-axillary 
regions; as the effusion increases the dullness is 
merged into flatness, (which finds its highest level 
in the axillary region, descending in front and be- 
hind, but varying as the patient assumes the sitting 
or reclining position). 

Auscultation: — The respiratory sounds are lost 
or diminished over the effusion, while immediately 
above the fluid the breath sounds are broncho-vesic- 
ular harsh, and exaggerated; vocal resonance is 
either absent or diminished over the fluid, while 
at its upper border egophony may be heard when 
the effusion is large. On the opposite side the 
breath sounds are intensified. 

When the effusion is greater the following signs 
are present. 

Inspection: — The patient seeks a position that 
will not interfere with action of the healthy lung^ 



SERO-FIBRINOUS PLEURISY. 213 

there are indications of cyanosis, and in some cases 
anemia and emaciation. The affected side may 
show enlargement and the lower intercostal spaces 
are wider than normal, but there is seldom any 
bulging and the respirations are increased in fre- 
quency. Dyspnea, while present all the time is 
increased upon exertion. The respiratory move- 
ments are restricted upon the side involved and 
correspondingly increased upon the healthy side. 
The apex beat of the heart is displaced to the 
opposite side from the effusion. 

Palpation: — This shows the affected side to be 
enlarged and its movements restricted. The inter- 
costal spaces are wider than normal, and in some 
cases they are filled out. Occasionally a sense of 
fluctuation is obtained by placing a finger upon an 
intercostal space and making gentle percussion upon 
the opposite side of the chest. The vocal fremitus 
is absent except along the lines of pleural adhesion, 
or when conducted from the sound side, and in the 
case of children, when it may remain for some 
time. The pulse is small, of low tension, rapid 
and often irregular. 

Mensuration shows the affected side to be en- 
larged and to have a diminished range of motion. 

Percussion: — This shows flatness over the effu- 
sion. The flatness may be found all over the 
affected side except in the upper portion of the 
interscapular region, where there is dullness due to 
the presence of the compressed lung. At times a 
vesicule-tympanitic note is obtained in the supra- 
clavicular and supra-scapular regions, the result of 
a vesicular emphysema. When the effusion is upon 
the left side it displaces the spleen downward and 



214 SERO-FIBRINOUS PLEURISY. 

obscures the tympanitic note from the stomach. 
The hVer dullness may extend as low as the um- 
bilicus, while the area of cardiac dullness is also 
displaced. 

Auscultation: — The vocal and respiratory sounds 
are absent over the effusion and are only feebly 
heard over the compressed lung in the interscapular 
region. At times, in cases of pronounced serous 
effusion, a whisper resonance can be detected; this 
is not present when the effusion is purulent. By 
auscultation the heart may be located when it is 
impossible to detect it by inspection or palpation. 
A systolic murmur may be heard over the heart 
which disappears with the effusion. 

Com-plications mtd Sequelce: — Sudden death may 
take place when an effusion is appearing rapidly; 
this is due to syncope from a fatty heart, from a 
thrombosis of the pulmonary artery, or right heart, 
or pulmonary edema, or it may occur during aspi- 
ration. It may be complicated with peritonitis, 
gangrene, empyema, nephritis, amyloid disease, and 
chronic interstitial pneumonia may follow it- 

Diagnosis: — The diagnosis must depend upon 
the physical signs to a great extent. It is true 
that there may not be many subjective symptoms, 
but the patient should receive a careful physical 
examination. At times, in localized effusion, the 
exploring needle should be resorted to as a means 
of diagnosis. Croupous pneumonia is the chief dis- 
ease from which it should be differentiated. 

Prognosis : — Except in those cases where it is 
the result of some grave disease, as tuberculosis, it 
is not a serious complaint; but the cause should 
always be taken into consideration. It should be 



SERO-FIBRINOUS PLEURISY. 215 

borne in mind that sudden death may take place, 
due to a thrombosis of the right side of the heart. 

Treatment : — These cases demand much the 
same form of treatment as plastic pleurisy during 
their early stages. The patient should be placed in 
bed, and if there is much pain it should be relieved 
either by applications or by restricting the move- 
ments of the side by means of adhesive straps. 
The diet should be dry and nourishing. As the 
effusion appears, local applications that are slightly 
irritating in character may be of service. During 
this stage as little fluid as possible should be given, 
restricting it to two ounces, while the diet should 
be as dry as possible, eggs, bread and meats form- 
ing the main articles of diet. 

The activity of the skin and kidneys should be 
favored as far as possible, and hot vapor or tub 
baths employed each day. Epsom salts have been 
used with good results in some of these cases, a 
dose from one-half to one ounce half an hour before 
breakfast. If the patient is rugged it may be given 
every morning; if not, every other morning. 

When the pleura is well filled, or is attended 
with distress of breathing, or when the effusion 
shows no tendency to be absorbed after a duration 
of from six to eight days, or is becoming purulent, 
or when there are heart lesions present, paracen- 
tisis should be performed. Following the attack 
systematic lung gymnastics and massage are of ser- 
vice in developing the injured lung. 

Cantharis: — When the physical signs indicate 
that a profuse sero-fibrinous exudation has taken 
place. There is threatened syncope with dyspnea 
and palpitation of the heart. The urine is dimin- 



2l6 SERO-FIBRINOUS PLEURISY. 

ished in quantity, and contains albumen, while the 
perspiration is profuse. The patient complains of 
great physical weakness. 

Apis mellifica: — It is during the later stages of 
the disease that this remedy is indicated, when the 
effusion is present and of a recent origin. There 
is an absence of thirst, the urine is dark and 
scanty, and there is edema of the chest wall.- In 
the dropsy following scarlet fever it will assist in 
favoring re-absorption. 

Bryonia: — This remedy has an influence in the 
early stages of the sero-fibrinous pleurisy, but when 
the effusion is large its usefulness is past. 

Colchicum: — This remedy is often of service in 
cases dependent upon rheumatic poison. There is 
present a sour smelling perspiration, the urine is 
scanty, turbid, and contains albumen. 

Rhus toxicodendron: — This is also indicated in 
rheumatic cases appearing after exposure to wet, or 
as a result of straining or lifting; the patient is ex- 
ceedingly restless notwithstanding the pain. 

Arsenicum album: — When, during the late stage 
of the disease, the effusion is not yielding to other 
remedies, and recurs after tapping; there is great 
dyspnea, with prostration; the patient being weak, 
cachectic, cyanosed and restless. 

Sulphur: — When the general symptoms indica- 
ting this remedy are present, together with a lack 
of reaction, this remedy should be studied. 

Asclepias tuberosa: — In pleurisy where there is 
a dry, hacking cough, with but little expectoration; 
the patient finds relief from bending forward. There 
are sharp, shooting, stitching pains. This remedy 



SERO-FIBRINOUS PLEURISY. 2l7 

is of service in the pleurisy that is associated with 
pneumonia and tuberculosis. 

Thoracentesis: — This is indicated when the 
effusion interferes with the respiration and the cir- 
culation, and shows no tendency to be absorbed by 
other methods of treatment; when it has existed 
until there is danger of permanent injury to the 
lung, and when there is effusion into both cavities. 
In choosing the point for paracentesis, it must be 
determined that the heart, spleen, liver, and dia- 
phragm will not be injured by the puncture, and 
that the lung is not adherent at this point. When 
not contra-indicated the mid-axillary line at the sixth 
intercostal space is a desirable point, as the chest 
wall is thin and the intercostal spaces roomy; there 
is not much danger of injuring the diaphragm here, 
and it is accessible when the patient is reclining. 
The part should be prepared in an aseptic manner. 
The patient should sit up, and reclining to the 
opposite side, rest the hand of the affected side 
upon the opposite shoulder, take a deep inspiration, 
and hold the breath while the needle. is inserted. 
The point should be anesthetized, either with a 
local anesthetic or by freezing with a small piece of 
ice that has been dipped in salt and applied firmly 
to the side for about thirty seconds. The part 
should then be wiped and a small incision made 
through the skin; the needle, guarded by the finger 
that it may not pass in too deeply, is inserted by a 
quick thrust through the pleura, just at the upper 
border of the rib. 

The needle should be clean, and the bottle and 
aspirator in good working order. The fluid should 
be withdrawn slowly; all of it need not be with- 



2l8 SERO-FIBRINOUS PLEURISY. 

drawn at one time. If, during the removal of the 
fluid, there should be a severe cough, urgent 
dyspnea, pain, faintness, syncope, or any blood in 
the fluid, the procedure should be stopped at once,, 
and the finger held over the opening until such 
time as cotton and collodion, or strips of adhesive 
plaster are applied. 

During the withdrawal of the fluid should the 
needle become blocked by a plug of false membrane 
it will be necessary to pass a blunt pointed plunger 
through the needle. It is nev^er desirable to remove 
a large quantity of fluid too rapidly, for the sudden 
congestion of the previously compressed lung has 
been observed to give rise to a profuse expectora- 
tion of albuminous fluid. 

Sudden death has occurred in rare cases follow- 
ing aspiration. This has been attributed to sudden 
cerebral or bulbar anemia. B}^ giving the patient 
a little brandy and water or some other stimulant, 
before or during the operation, syncope etc. may 
be prevented. Usually when a portion of the fluid 
is removed the remainder is absorbed. Should the 
cavity refill rapidly it should, if possible, be ascer- 
tained whether the compressed lung is not bound 
down by adhesions which prevent its expanding. 
In such a case the repeated withdrawals would but 
exhaust the patient. 

Following aspiration there may be a trouble- 
some cough, dependent upon a little mucus in a 
partially compressed bronchial tube. A drink of 
warm milk with seltzer or apollinaris water, with a 
little brandy or whiskey, repeated every two or 
three hours, usually brings relief. 



CHAPTER XXIII. 
DIAPHRAGMATIC PLEURISY. 



Definition: — This is an inflammation of the 
pleura which covers the diaphragm and under sur- 
face of the lung. 

Etiology : — It is dependent upon the same 
causes that give rise to pleurisy elsewhere, and has 
the same pathology. It is attended most frequently 
with a sero-fibrinous exudate. 

Symptoms : — The symptoms are hard to inter- 
pret. In the majorit}^ of cases the onset is indicated 
by a sharp chill and high fever, 103° to 104°, 
while the pain is excruciating. It is referred either 
to the abdomen, low down in the back, or to the 
costo-phrenic attachment along the tenth rib, where 
tenderness may be elicited. The pain is increased 
by coughing, hiccough, and by an attempt to 
speak. Vomiting is a frequent s3^mptom and the 
bowels are constipated. In severe cases delirium 
may appear, and is often a forerunner of coma. 

Physical signs: — These are often absent. 

Inspection: — The face has an expression of great 
anxiety, which is rendered more pronounced by the 
patient endeavoring to restrict the movements of 
the inflamed diaphragm. He often sits shghtly 
bent forward, supporting the sides with the hands 
to assist in limiting the movements of the diaphragm, 
or he may be in a semi-reclining position with the 
knees drawn up; the respirations are short, rapid, 



220 DIAPHRAGMATIC PLEURISY. 

superficial, and restricted to the lower portion of 
the affected side of the chest. 

Palpation: — The abdomen is sensitive to pres- 
sure, its muscles are tense and contracted. There 
are tender points along the course of the phrenic 
nerve. 

Percussion: — If there is much effusion there 
may be an area of tlatness, with a displacement of 
the liver downwards when the pleurisy is on the 
right side. 

Auscultation : — This may reveal a friction sound 
at the base of the chest, but usually this is absent, 
and the respiratory murmur is deficient at the base 
of the chest, owing to the immobility of the dia- 
phragm. 

Diagnosis: — This is not easy. Many of these 
cases are mistaken for peritonitis or other abdomi- 
nal diseases. Friction may be present and the 
points of tenderness be recognized. The abdomen 
is not distended, the pain is superficial, is made 
worse by the cough, and there are deep respira- 
tions; the dyspnea is much more marked than in 
abdominal affections. 

Prognosis : — This is usually favorable. The 
fatal cases are those in which the effusion is either 
purulent or w^here severe complications are present. 

Treatment: — This is the same as in the other 
forms of pleurisy. 



TUBERCULAR PLEURISY. 221 

TUBERCULAR PLEURISY. 

Tubercular infection of the pleura presents the 
same classification as is met with elsewhere, being 
acute, sub-acute and chronic. 

The infection usually reaches the lung through 
the lymphatic system. The visceral layer is in- 
fected from the bronchial and tracheal glands, while 
the parietal layer is infected from the cervical and 
mediastinal glands. The lungs are here as fre- 
quently a source of infection as is the peritoneum 
in other cases. In rare cases it may originate pri- 
marily in the pleura. 

In the acute form it is frequently ushered in by 
a distinct chill, when it may appear as a complica- 
tion of some chronic disease. In this as well as in 
the more chronic type there is a constant tendency 
to re-accumulation of the fluid, after paracentesis, 
with marked thickening and adhesion of the pleura; 
these last symptoms being considered by many as 
indicative of the chronic form. A general miliary 
tuberculosis is met with here as well as in other 
serous cavities. The diagnosis of tubercular pleurisy 
is often difficult to make. It may be inferred 
in those cases where there is a family history of 
tuberculosis, a ph37sique that is favorable for its 
development, and enlarged glands; also in those cases 
where the disease is of long duration, with refilling 
of the pleural sac after repeated withdrawals of the 
fluid, accompanied by thickening of the pleura and 
retraction of the side. In a percentage of the 
cases the bacilli can be demonstrated in the fluid, 
but their absence proves that it is not of tubercular 
origin. 



222 TUBERCULAR PLEURISY. 

The prognosis is more favorable than in tuber- 
culosis of many other organs, and yet a percentage 
of these cases develop pulmonary tuberculosis later 
in life. 

The case demands much the same treatment as 
is indicated in cases of pleurisy arising from other 
sources, with the addition of the tubercular infec- 
tion. The patient must be well nourished and such 
means should be adopted as will promote the ab- 
sorption of the exudation and develop the retracted 
lung. If there is a tendency of the fluid to re-ac- 
cumulate after withdrawals, and the patient can be 
gotten into the sunshine and open air, this will 
usually control the condition. If the heart is sound 
great benefit will be derived from a high elevation 
and pulmonary gymnastics to expand the lungs. 

The treatment of tubercular empyema is often 
difficult, as a fistula frequently results owing to the 
thickening of the pleura. 



CHRONIC PLEURISY. 

Definition : — This is a chronic inflammation of 
the pleura, and may be dry or accompanied by an 
effusion. 

CHRONIC DRY PLEURISY. 

Etiology: — This may be the result of an acute 
or of a chronic sero-fibrinous pleurisy, or it may 
be primar3^ 

Pathology : — As the effusion is absorbed the 
pleural surfaces are brought together, and the 
fibrous elements become organized into layers 



CHRONIC PLEURISY. 2 23 



which bind the already thickened pleurae together. 
This process is most marked at the base of the 
lung, which is compressed and shows fibroid 
change. In those cases where the process has been 
dry from the start the exudate becomes organized. 
In most cases it is tubercular, and most marked at 
the apex. 

Symptoms: — Neither the general symptoms nor 
the physical signs are definite and constant during 
the earlier stages. Later there is a failure in the 
nutrition, following repeated attacks of acute bron- 
chitis. Chronic bronchitis and bronchiectasis often 
become established. Dj^spnea is present and the 
urine contains albumen. 

Physical signs : — Inspection. This usually shows 
a constriction and immobility of the affected side, 
with a compensating enlargement of the healthy 
side. The heart is displaced, the spinal column is 
curved, the 'scapula dislocated, the shoulder of the 
affected side is drooping, the lower part of the 
thorax shrunken, and the ribs of that side are 
closely approximated. 

Palpation: — The tactile fremitus is decreased or 
wholly absent on the affected side. 

Percussion: — The percussion resonance is im- 
paired, while dullness is increased in proportion to 
the thickness of the pleura and the fibroid change 
in the lung. 

Auscultation: — This shows the breath sounds to 
be feeble, and at times a dry, leathery, creaking 
friction sound is heard. 

Diagnosis : — This is based upon the history of the 
case, the general symptoms, and the physical signs. 



224 CHRONIC PLEURISY. 

Prognosis: — This must depend upon the care 
the patient can take of himself, and the etiology of 
the disease. When it is tubercular it is not ulti- 
mately good. 

CHRONIC PLEURISY WITH J:FFUSI0N. 

Etiology : — This may result from an acute sero- 
fibrinous form, or it may be of a slow and gradual 
development known as " latent." 

Pathology : — This often resembles the more 
acute t3^pes, and is attended with the same displace- 
ments of the surrounding organs; when the fluid is 
either absorbed or removed there are the same 
fibrous formations, adhesions, and retractions as are 
met with in other forms. 

Symptoms: — There are at times no subjective 
symptoms, but in most cases there is a slight 
dyspnea upon exertion. The evening temperature 
is at times higher than the morning. Should the 
effusion become purulent a hectic condition is de- 
veloped. The pulse is rapid and compressible. 
The fingers and toes are often clubbed. There 
may be slight pain or distress. The respirations 
are increased in frequency as well as the pulse, 
which may average loo to the minute. 

Physical signs: — These are similar to those 
found with acute sero-fibrinous pleurisy. 

Diagnosis: — This is based upon the history of 
the case, its prolonged duration, and the physical 
signs. 

Prognosis: — The duration of these cases is from 
a few months to several years. Death may be due 
to asthenia, or intercurrent or secondary suppura- 
tion. 



CHRONIC PLEURISY. 2 25 

Treatment : — These two conditions demand much 
the same treatment. Where an effusion is present 
it should be removed and its character ascertained, 
that it may be known whether there is a suppurative 
process present or not. The rules for its removal 
have been considered under sero-fibrinous pleurisy 
and empyema. 

The nutrition of these patients must be im- 
proved, the diet being adapted to the case. If the 
case is tubercular the diet should contain those 
articles that are known to assist in overcoming the 
disease, while if rheumatic dietary precaution should 
also be observed. Means must be adopted to ex- 
pand the injured lung. To this end pulmonary 
gymnastics, if systematically practiced for some 
time, are of service, the affected side being the one 
to which most of the attention is devoted. A 
change of climate to an atmosphere where the air 
is rarer, so that deeper breathing is demanded, is 
of great service. If such a change is possible it 
should be made early, as it is difficult to make 
any improvement in the cases after permanent ad- 
hesions are formed. 

Sulphur: — The deep constitutional action of this 
remedy, together with the clinical results, leads us 
to place it first upon the list. It should be studied 
when the apparently indicated remedy has ceased to 
act. The left lung is the most affected, there 
being pains through the side and back. The pa- 
tient may be rheumatic or gouty, is tall, lean, with 
stooped shoulders, with a history of slow recoveries 
from illnesses and relapses. There are weak, faint 
spells, with a feeling of suffocation from time to 



226 CHRONIC PLEURISY. 



time. The feet are cold, the lips and tip of the 
tongue are very red, and all symptoms are worse 
about II a. m. 

lodium: — This remedy and its compounds will 
be found serviceable in scrofulous subjects where 
the exudate is not being absorbed. The patient is 
very weak and greatly emaciated, although he has 
a ravenous appetite; and he feels relieved of all his 
ills only when eating or immediately after eating. 
In some cases, with marked indications of their 
tubercular origin, the syrup of hydriodic acid will 
be found more serviceable than the iodine. These 
cases are often benefited by cod liver oil on . account 
of the iodine contained in it. 

Hepar sulphur: — This remedy should be studied 
in chronic pleurisy when there is dyspnea, with a 
constant pain in the side. There are chills and a 
fever that is hectic in character, with profuse 
sweats and emaciation. 

Silicea: — This remedy is of service in cases 
where the patient is irritable, nerv^ous, pale; the 
face is pinched, the patient is weak and suffers 
from diarrhea and night sweats. 

Arsenicum iodatum: — This remedy or arsen- 
icum album will be needed in some cases where 
there is dyspnea with a dry cough, a slight rise of 
the temperature, and indications of tuberculosis. 

Kali carbonicum: — This is of service in the 
severe stitching pains that accompany pleuritic ad- 
hesions; they appear independently of any motion. 



1 



CHAPTER XXIV. 
EMPYEMA. 



Synonyms: — Purulent pleurisy, suppurative pleu- 
risy. 

Definition: — This is a collection of pus in the 
pleural cavity. 

Etiology: — It may be primary, but more fre- 
quently it is secondary. The great distinction be- 
tween the effusion of sero-fibrinous pleurisy and 
empyema is the, presence in the latter of micro- 
organisms, of which the streptococcus pyogenes is 
most frequently observed, the pneumococcus of 
Frankel being next in frequency. The other micro- 
organisms that are occasionally found are the 
staphylococcus, and the bacillus of Eberth. The 
fetid and putrid character of the effusion that is 
occasionally met with is due to the saprophytic 
bacteria. Empyema may appear as a sequence of 
acute sero-fibrinous pleurisy in those with impover- 
ished systems, but it is more frequently observed 
in secondary pneumonia, scarlet and typhoid fevers, 
bronchiectasis, pulmonary abscesses, pericarditis, 
abscesses of the cervical and bronchial glands, 
liver, spleen and mediastinum. It may also appear 
as a result of a general septic condition which 
occurs in pyemia and septicemia. Cases have been 
reported following dysentery and appendicitis. 
Injuries to the chest wall, in the form of fractured 
ribs, punctured wounds, and occasionally thoracen- 
tesis, when not performed aseptically, may termi- 



228 EMPYEMA. 



nate in empyema. It is often primary in children. 

Pathology : — Microscopic examination shows 
that the inflammatory products are identical with 
those of purulent inflammation in general. The 
exudate varies in appearance and consistency. At 
times it is thin, slightly clouded, with no marked 
line to distinguish it from a sero-fibrinous exudate 
except for the number of pus cells present, while 
in other cases it is thick and opaque. The odor 
from the exudate is sweet, or if the empyema is 
the result of gangrene it is very offensive. The 
pleura shows the result of a more intense inflam- 
mation than it does in sero-fibrinous pleurisy. 
There is a deeper infiltration with round cells and 
leucocytes, while the lymph spaces are engorged 
with pus and the blood vessels are dilated. 
Should the empyema be of long standing the 
pleura will show great thickening, while the lung 
is correspondingly compressed. If the effusion is 
not removed necrosis of the pleura may involve 
the whole of the pleural cavity, or be encapsuled 
at any point. 

Symptoms : — The onset of the empyema varies; 
at times it is abrupt. There are severe and re- 
peated chills followed by a high temperature, 
( 102° to 105° F.) with great prostration; cold, 
clammy, sweats, severe pains in the affected side 
upon movement and breathing, accompanied by 
marked dyspnea. In other cases the onset is 
gradual, accompanying or following some one of 
the acute or infectious diseases. The pain, cough 
and dyspnea may not be present, and there is 
nothing to call attention to its presence until the 
pleural cavity is about filled. The symptoms are 



EMPYEMA. 229 



those of a septic condition, as weakness, wasting, 
dry tongue, sordes upon the teeth, rapid pulse, 
tendency to delirium, and a general typhoid state. 
The temperature curve is usually such as indicates 
a septic condition. The primary disease may 
mask the appearance of the emyema for a time. 
The temperature assumes the hectic type, accom- 
panied by sweating, chilly sensations, and a 
gradual loss of flesh and strength. The face 
becomes pale, the dyspnea increases, and the 
cough is dry, hacking, and long continued. The 
urine contains albumin. Peptonuria, while not 
found alone with empyema, is frequently to be 
demonstrated. An examination of the blood shows 
leucocytosis. Absorption rarely, if ever, occurs 
when the infection is due to the streptococcus, 
but when due to pneumoccoccus, absorption may 
occur. The primary disease, and later the typhoid 
state, may be such as to wholly obscure the em- 
pyema. 

Physical signs: — These are much the same as 
those described under sero-fibrinous pleurisy, which 
should also be studied. 

Inspection: — This may show a slight edema of 
the chest walls, especially in children; this is not 
as noticeable in sero-fibrinous pleurisy; also, the 
patient presents more of the signs of a septic in- 
fection. 

Palpation: — See sero-fibrinous pleurisy. 

Percussion: — This may show that the upper 
level of the fluid does not change as rapidly as in 
pleurisy. 

Auscultation: — This adds no new signs. 



230 EMPYEMA, 



Pulsating empyema: — This is a pulsation that is 
synchronous with the heart's beat. It is present 
when there is large effusion and a relaxed condi- 
tion of the thoracic walls, due to paralysis of the 
intercostal muscle, combined with a forcible heart's 
action. 

Diagnosis: — The presence of a pleural effusion 
is based upon the physical signs. To positively 
state that it is purulent, aspiration must be re- 
sorted to; as the chills, edema, sweating and fever 
may be present in sero-fibrinous pleurisy. 

Prognosis: — This should always be guarded. 
Surgical interference renders it more favorable than 
formerly, yet in these cases there is obliteration 
of the pleural cavity and retraction of the side. 
Spontaneous absorption, although it has been re- 
ported, is rare. Rupture may take place exter- 
nally, and terminate favorably, or yet internally, 
through the bronchi. In cases where evacuation 
takes place, suppuration may follow for a long 
time and a condition of asthenia result. In chil- 
dren the prognosis is better than in adults. Bilat- 
eral empyema is more serious than when unilateral. 
The complications must be considered in giving a 
prognosis. 

Treatment : — When the physician finds that he 
has a case of empyema to treat his aim should be 
to maintain the strength of the patient. The 
dietetic treatment must be such as will meet the 
drain on the system due to the constant formation 
of pus. To this end fatty foods should be em- 
ployed, as butter, cod liver oil, cream, and much 
the same diet as is recommended in tuberculosis. 



EMPYEMA. 231 



together with such hygienic means as will assist to 
maintain the strength. 

When it is known that there is pus in a pleu- 
ral cavity it must be removed. Although cases 
have been reported in which the pus has been 
absorbed, this is not the rule and the expectant 
treatment is attended with danger and the loss of 
valuable time. The first question is whether aspi- 
ration will be sufficient, or whether the case de- 
mands incision and drainage. In the case of 
children it will usually be found sufficient to 
aspirate. This may be done several times if 
needed. 

Before undertaking an operation for empyema 
the age of the patient, the nature of the cavity, 
whether localized or general, whether the pleura 
is thickened, whether the lung is adherent at any 
point, and whether the ribs are approximated, 
should be ascertained. The opening should be 
sufficient for free drainage, and one that will re- 
main open until it is necessary to remove the 
drainage tube; and it should be in such a location 
that it will afford free drainage in whatever posi- 
tion the patient chances to be. The only advan- 
tage of a simple incision over a resection of a 
rib is that the operation can be done with a local 
anesthetic, avoiding general anesthesia. 

If a general anesthetic is employed chloroform 
is preferable to ether, as the respirations are 
easier under its use. The operation should be 
preceded by an exploratory puncture. Like all 
other operations, cleanliness should be thorough. 
The incision should be about two inches long in 
the selected intercostal space, keeping close to the 



232 EMPYEMA. 



Upper border of the lower rib in order to avoid 
the intercostal artery. The pleural cavity is then 
reached, either by dissections, or by a grooved 
trocar, along which the knife is thrust into the 
cavity. When most of the pus has escaped a 
drainage tube of good size is inserted, being pro- 
tected from passing more than two inches into 
the cavity by a safety pin. A dressing is applied 
that envelopes the whole side and arm, care being 
taken that the axilla is well padded. 

In adults where a general anesthetic is em- 
ployed the resection of two inches of a rib is 
preferable to a simple incision as it allows a freer 
drainage, the escape of fibrous particles, and the 
introduction of the finger to open up the cavity 
about the drainage. The patient being prepared 
and anesthetized an incision about three inches long 
is made on the middle of the sixth or seventh rib in 
the axillary region, the periosteum is then crowded 
to the side by means of an elevator, the rib is 
divided, resecting at 'least an inch and a half. 
The pleura should not be opened during this part 
of the operation. After the rib has been removed 
the pleura should be opened and one or two 
fingers inserted to free the pleura and open up 
the cavity. The pus must not be allowed to escape 
too rapidly. Drainage should be introduced and a 
dressing applied. When a fistula exists it is ad- 
visable to make the incision in the usual place and 
treat the case as though no fistula existed. When 
double empyema exists one side should be operated 
on first, then after a few days have been allowed 
to elapse, the other side may be drained. 

Irrigation is injurious and retards, rather than 



EMPYEMA. 233 



hastens recovery. Drainag^e should always be as 
perfect as can be effected; the patient should lie 
as much as possible upon the affected side, at 
times half reclining, again with the shoulders low, 
that the pus may gravitate to the opening. 
Manipulation over the chest three or four times a 
day is of service. 

The first dressing should be removed at the 
end of two or three days, while later, dressings 
may remain for a week. The drainage tube should 
be cleaned and shortened as closure takes place. 
Should no complication appear the patient may 
be allowed to walk about in from seven to ten 
days. As the strength returns the lungs should 
be expanded. To this end the use of Wolff bot- 
tles, or a residence in a dry atmosphere is of ser- 
vice. When the lungs do not expand and the 
pus cavity is not obliterated, retraction of the 
chest wall must be produced. This may be 
accomplished by firm strapping of the affected 
side for a long period of time, but usually such 
an operation as Estlander's must be resorted to; 
for a description of this the reader is referred 
to a text book on surgery. 

One of the following remedies may be of ser- 
vice when drainage has been established. 

Silicea: — This remedy is frequently of service 
in cases where the suppuration is chronic, and 
although the drainage is good, yet the pus con- 
tinues. The pus is thin and sanious. The patient 
becomes emaciated, is weakly, and is usually of a 
light complexion, with fine dry skin, and pale face. 
He is made worse by cold, and by uncovering, 



234 EMPYEMA. 



especially the head, and is relieved by warmth 
and by being wrapped up. 

Hepar sulphur: — This will be of service in 
those of a torpid, lymphatic constitution, in whom 
the slightest injury causes suppuration. He is 
over-sensitive, both physically and mentally. The 
pus is apt to be foul and drains away slowly. 
Hectic fever is present, the patient is emaciated 
and has repeated attacks of chilliness, fever and 
sweats. The sweats are profuse, sour and offen- 
sive. 

Calcarea carbonica: — When this remedy is indi- 
cated the patient has light hair and complexion, 
with blue eyes, fair skin, and a tendency to obe- 
sity. She is weak, pale, tires when walking, 
sweats easily, and takes cold readily. The calca- 
rea fluorica should be remembered when the empy- 
ema appears in cases of acute phthisis; calcarea 
sulphurica should be studied when the empyema 
complicates the eruptive fevers. The calcarea 
phosphorica and calcarea hypophosphorica should 
be remembered in tubercular cases, when the 
patient is spare, dark colored and anemic. 

Arsenicum album: — This remedy is indicated 
by the great prostration with rapid sinking of the 
vital forces and mental restlessness; the patient is 
anxious, fearful, restless, full of anguish, and 
worse from i to 2 a. m., and i to 2 p. m. There 
is relief from heat. In some cases the iodide of 
arsenic will be found to act better when the 
above symptoms are accompanied by involvement 
of the glandular system and acrid discharges. 
Chininum arsenicosum should be studied when 



EMPYEMA. 235 



with the symptoms of arsenic there are the distinct 
and regular appearing hectic symptoms. 

Sulphur : — This remedy should be studied when 
there are the general symptoms indicating it, as 
great shortness of the breath with oppression, and 
distress about the chest, with general debility. 

Psorinum: — This is to be remembered when 
the pus and other discharges are very offensive. 

Sodium sulpho-carbolate: — In from three to 
five-grain doses every three hours; this is of ser- 
vice when septic symptoms complicate the em- 
pyema. 

Echinacea augustifolia: — This remedy should 
be remembered; it is usually given in five-drop 
doses of the tincture. 



CHAPTER XXV. 
PNEUMOTHORAX. 



Definition: — This is an accumulation of air or 
other gases in the pleural cavity. 

Etiology: — It may arise as the result of a per- 
foration of the pleura, either from without or with- 
in, or from a spontaneous generation of gases 
within the pleural sac, though the latter rarely if 
ever occurs. 

It is seldom that air is found alone; usually 
there is associated with it either a serous or pur- 
ulent effusion, producing what is known as hydro- 
pneumothorax, or pyo-pneumothorax, and occasion- 
ally there is blood, giving rise to hemo-pneumo- 
thorax. Many of these cases due to external per- 
foration are the result of traumatism, as stabs, 
gunshot wounds, blows, operations, fracture of the 
ribs, and caries of the ribs. 

The cases that arise as a result of perforation 
from within are most frequently the result of 
ulceration from tubercular cavities, extending 
through the pleura, or caseous tuberculosis, 
abscesses, gangrene, and broncho-pneumonia. 
Emphysema and empyema are less frequent. The 
perforation may be through the diaphragm as the 
result of a sub-phrenic abscess. It occurs more 
frequently in males than in females, and upon the 
left side than upon the right. 

Pathology : — The degree of distension of the 
pleural sac varies. If it is considerable, the lung 



PNEUMOTHORAX. 237 



is pushed back against the spine; it is greyish or 
brovv^nish in color, airless and hardened. The air 
may be absorbed and the pleura remain in a 
healthy condition, but more frequently infection 
takes place and a purulent collection forms in the 
sac, known as pyo-pneumothorax. The surround- 
ing organs are displaced in proportion to the 
amount of air present. When it is upon the left 
side the heart may be displaced to the right of 
the sternum, while if it is upon the right side the 
liver is displaced downwards. 

Sy^n^toms : — In the majority of these cases, as 
when rupture of the pleura takes place, there 
is a sudden and agonizing pain in the upper por- 
tion of the chest or back. The pulse and respira- 
tion are greatly increased in frequency and the 
dyspnea may be distressing. There is cyanosis, 
and an expression of anxiety about the face. The 
alse nasi are greatly distended, and all the auxil- 
iary muscles of respirations are called into activity. 
The temperature is lowered, the surface of the 
body is bathed in a cold perspiration, and marked 
symptoms of collapse are present. This may 
occur during a severe paroxysm of coughing, and 
the dyspnea may be so severe that the patient is 
obliged to sit up, or he may choose a recumbent 
posture, lying upon the affected side. The sever- 
ity of the early symptoms depend upon the pre- 
vious activity of the lung; if it had been impaired 
by disease the loss sustained may scarcely be felt. 
The same is true if the opening is small and the 
escape of the air is slow and gradual, so that the 
healthy lung has time to adapt itself to the extra 
task imposed upon it. It is not uncommon dur- 



238 PNEUMOTHORAX. 



ing an examination to find such a condition, of 
which the patient is wholly ignorant. Should the 
air escape rapidly into the pleural cavity surround- 
ing a healthy lung, the symptoms will be urgent. 

The fall in the temperature at this time varies 
according to the range of fever; if high, it may 
be five or six degrees; while if the fever is low, 
the fall will be correspondingly less. Following 
the shock the temperature may return to nearly 
the same range as before. If there is little or no 
inflammation the temperature will remain at nearly 
the normal point. The acute symptoms, which are 
the result of the shock, may subside after a few 
hours, but the breathing continues rapid and may 
increase in frequency as the air accumulates in the 
pleural cavity. 

Physical signs : — Inspection. The patient pre- 
sents a cyanosed appearance at the time of the 
perforation. In many cases there is emaciation 
and pallor. The affected side becomes enlarged and 
motionless; the intercostal spaces are seen to be 
full, wide, and frequently bulging, and do not 
recede during inspiration. The respiratory move- 
ments are increased on the sound side, and lost 
over the diseased side. Should there be pleural 
adhesions the loss of movements may be localized. 
The apex beat of the heart is displaced toward the 
healthy side. There is dyspnea and even orthop- 
nea during the early stages, which later may not 
be noticed except during exertion. 

Palpation: — Vocal fremitus is lost over the af- 
fected side unless there are bands of adhesion, when 
it may be retained to a slight extent. The pulse 
is rapid and feeble. The lower line of the liver 



PNEUMOTHORAX. 239 



dullness and the apex of the heart should be located 
if possible, that the amount of displacement may be 
ascertained. Succussion fremitus is indicative of a 
hydro-pneumothorax. 

Mensuration: — This shows the affected side to 
be enlarged and motionless. 

Percussion : — The percussion note over air is 
ususally tympanitic, this varying with the amount 
of air present and the degree of tension. When a 
large opening communicates with a bronchus the 
resonance may be amphoric. Where fluid is pres- 
ent there is flatness over the lower part of the 
chest, which changes with the position of the pa- 
tient; over the sound side there is hyper-resonance. 

Auscultation: — Over the air the vesicular mur- 
mur is absent while the respiratory and vocal sounds 
are feeble or amphoric. If fluid is present all sounds 
are absent over the compressed lung, or they are 
bronchial and feebly transmitted, if heard at all. 
Rales of a metallic character may be heard as well 
as metallic tinkling. When shaking the body a 
succussion of splashing sounds may be heard if 
fluid is present. 

Diagnosis: — This is based upon the sharp pain 
in the side or back; the intense dyspnea and great 
oppression of breathing, which is shallow and rapid, 
the bulging of the chest on the affected side, the 
tympanitic percussion note, the enfeebled breath 
sounds, the metallic tinkling, and succussion sound 
if fluid is present. 

Pneumothorax should be differentiated from a 
pulmonary cavity, pleural effusion, diaphragmatic 
hernia and sub-phrenic abscess. 



240 



PNEUMOTHORAX. 



PNEUMOTHORAX. 

1. Phenomena is general. 

2. There is an acute exacerba- 
tion of pain, dyspnea and 
oppression with bulging of 
the side. 

3. There may be a percussion 
flatness due to an effusion. 



PULMONARY CAVITY. 

1. Is localized. 

2. None of these are present. 



Is absent. 



Both may yield a tympanitic resonance, an 
amphoric respiration, metallic rales, and succussion 
sound. 



PNEUMOTHORAX. 

1. Appears suddenly. 

2. If effusion is present there 
is a tympanitic note above it. 

3. Succussion sound is present 
when the pleural cavity con- 
tains both air and fluid. 

4. The clinical history reveals 
a condition that would pro- 
duce pneumothorax. 

PNEUMOTHORAX. 

1. Has a definite time of ap- 
pearance. 

2. May have succussion 
sounds. 

3. The result of disease of the 
lung or injury to the pleura. 

PNEUMOTHORAX. 

I. There is a previous history 
of disease of the lungs. 

PNEUMOTHORAX. 

1. Is unilateral. 

2. Often there is a lateral dis- 
placement of the heart. 

3. Resonance is tympanitic. 



PLEURAL EFFUSION. 

1. Appears slowly. 

2. No tympanitic note above 
the flatness. 

3. It is not present. 



4. There is a history of pleural 
inflammation. 



DIAPHRAGMATIC HERNIA. 

1. May date from birth. 

/ 

2. Has rumbling sounds as 
heard in the intestinal tract. 

3. A different etiology. 

SUB-PHRENIC ABSCESS. 

I. A previous history of dis- 
ease of the stomach or bowels. 

EMPHYSEMA. 

1. Is bilateral. 

2. No lateral displacement of 
the heart. 

3. Not so markedly tym- 
panitic. 



PNEUMOTHORAX. 24I 



Prognosis: — In cases due to traumatism the 
opening may be closed with inflammatory exudate, 
the air be absorbed and recovery result. In those 
cases dependent upon a pathological cause the prog- 
nosis is grave. 

Treatment : — The treatment must be adapted to 
the particular case. If the pain is agonizing it may 
be necessary to give a hypodermic injection of mor- 
phine. When the shock is more pronounced a 
hypodermic injection of ether will be found of more 
service. When neither the pain nor shock is so 
severe, strapping of the side with adhesive straps is 
serviceable; when there is great dyspnea atropine 
will act well. If the cardiac action is feeble, either 
the aromatic spirits of ammonia, strychnia, or other 
cardiac stimulants are demanded. When the pain 
and shock have been relieved it must be ascertained 
if the pressure is still increasing, if so, the intro- 
duction of a fine trocar will give a degree of relief. 
This may be retained in place, and when the air 
has escaped the side should be firmly strapped. 
The straps should reach two or three inches beyond 
the median line. If great engorgement and lividity 
are present, attention should be devoted to the 
bowels, that they may be active and that there 
may be no obstruction to the portal circulation. 
The patient should be given food in small quantities 
at frequent intervals, but not such as will excite 
the heart's action. 

In cases of punctured wounds of the chest the 
air is admitted from without and there is no ten- 
dency for it to produce increasing d3^spnea. If no 
septic organisms have been admitted the air is ab- 
sorbed early and but little treatment apart from that 

16 



242 PNEUMOTHORAX. 



devoted to the wound is demanded. When a frac- 
tured rib has punctured the lung allowing the air 
to escape into the pleural cavity relief may be ob- 
tained by passing a trocar and canula through an 
intercostal space and leaving the canula there until 
such time as the lung has healed. This must be 
done with perfect cleanliness and an antiseptic 
dressing be applied about the chest. If blood has 
accumulated in the lower part of the pleural cavity 
the same form of treatment is applicable. 

Cases of hydro-pneumothorax, while aspiration 
may help them temporarily are benefited more by 
a free drainage. Cases of pyo-pneumothorax, if 
tubercular, are always of a chronic nature and may 
not present any symptoms apart from the shortness 
of the breath. The removal of the air or pus is 
only followed by a very temporary relief. A free inci- 
sion is nearly always attended with bad results. 
Although the patient may appear to improve for a 
time the lung does not expand, a septic condition 
soon follows, the tubercular infection becomes more 
active, and the patient succumbs to sepsis and 
tuberculosis. 

In cases where the amount of fluid is large and 
increasing something must be done; here aspiration 
may be tried and repeated from time to time. If 
this is not found to be sufficient it is well to irri- 
gate the pleural sac by inserting two needles, one 
in the anterior and the other in the posterior part 
of the chest, being sure that the lung is not adher- 
ent at these points. A rubber tube is attached to 
each needle, the anterior one being in a large bottle 
containing warm boracic acid solution of 100° F., 
that has been prepared in sterilized water, while the 



PNEUMOTHORAX. 243 



other tube is in a vessel on the floor and attached 
to an aspirator. When the irrigating fluid from 
the pleural cavity runs clear the anterior tube 
should be removed and all the fluid possible drained 
from the posterior. In tubercular cases where the 
air causes much dyspnea it may be removed by 
aspiration; where this is not sufficient a small can- 
ula inserted and held in place b}^ an antiseptic 
dressing is of service. 

The diet must be light and nutritious. The 
bowels should not be allowed to become constipated. 
In some cases prophylactic means may be adopted 
when it is believed that the cavities formed under 
the pleura are not protected by adhesions. Strap- 
ping the side, together with the emplo3'ment of 
such means as will allay the cough are indicated. 

The remedies that are indicated in phthisis and 
empyema may be of service. 



CHAPTER XXVI. 
HEMOTHORAX. 



Definition: — This is a collection of blood in the 
pleural cavity. 

Etiology: — Many of these cases are the result 
of traumatism that has resulted in a laceration of 
the lung, a fractured rib, an injury to an intercostal 
or internal mammary arter}^, intra-thoracic vein, or 
the rupture of an aneurysm. \\\ some cases pul- 
monary infarction has been known to rupture into 
the pleural cavity. Those diseases that give rise to 
a hemorrhagic diathesis also produce scurvy and 
purpura, while with Bright 's disease, the specific 
fevers, cirrhosis of the liver, pneumonia, cancer, and 
tuberculosis, an effusion of blood ma}' result. 

Pathology : — The amount of blood poured out 
may be just enough to give a tinge to the effusion 
or it may be of such an amount as to fill the 
pleural cavity and compress the lung. 

Symptoms: — The symptoms depend upon the 
amount of blood extravasated and the rapidity with 
which it escapes from the vessels. There is usually 
more or less syncope and pallor, with coldness of 
the extremities. The respirations are increased as 
the compression of the lung becomes more pro- 
nounced. 

Physical signs : — These are the same as the 
signs indicating pleural effusion. The percussion note 
shows a flatness that gradually extends from below 
upwards. 

Diagnosis: — The presence of an effusion is 



HEMOTHORAX. 245 



recognized by the usual physical signs. There is 
frequently the evidence of an internal hemorrhage. 
There is no fever, and a collection of fluid appear- 
ing rapidly after an injury is indicative of hemor- 
rhage. 

Prognosis: — This should be guided by the 
cause of the hemorrhage. In cases due to aneur- 
ysm and incurable diseases it is not good, while 
in traumatic cases the blood quickly coagulates and 
in time is absorbed, providing it is aseptic. 

Treatment : — The patient should be kept quiet 
and the expectant treatment so far as the hemor- 
rhage is concerned, is to be adopted. If the dysp- 
nea is distressing, an amount of blood sufficient to 
relieve it should be drawn off. The cause should 
always receive attention; if this is an injured vessel 
it should be tied if possible. The patient should be 
kept quiet. Arsenic is of service in some cases 
where hemorrhage is taking place, china for bad 
effects from loss of blood, while arnica, hamamelis 
and calendula should be remembered in cases due 
to traumatism. 



HYDROTHORAX, 

Synonym: — Dropsy of the pleura. 

Definition: — This is a transudation into the 
pleural cavity of a non-inflammatory serous fluid. 

Etiology: — It is a secondary condition depend- 
ent upon cardiac failure, chronic valvular diseases, 
Bright's disease, aneurysm, mediastinal tumors 
pressing upon the axygos veins, and debilitating 
diseases. 



246 HYDROTHORAX. 



Pathology : — The fluid is clear and contains a 
greater percentage of albumen than the dropsical 
fluid from other serous cavities. During the early 
stages of the effusion the pleura retains its glisten- 
ing, smooth appearance, while in the long standing 
cases the visceral layer becomes of a grayish white 
color, and is slightly thickened. The lower lobes 
of the lungs show the effects of pressure, and may 
be collapsed. 

Sy?nptoms: — When in a case of anasarca there 
is a gradually increasing dyspnea which may amount 
to an orthopnea careful physical examination should 
be made even if the patient is weak. There is no 
local pain, no fever, and many of the general symp- 
toms are those that are dependent upon the original 
disease. It may appear when there is but little 
edema of the extremities. In those cases where 
the hydrothorax is dependent upon an anemia or 
renal disease it is usually upon both sides; in cases 
due to heart disease it is usually on one side only, 
and if on both it is more marked on one side than 
on the other; in those cases where it is dependent 
upon venous obstruction it may be one or both 
sides. 

Physical signs: — Inspection. Upon the face 
there is an expression of anxiety with cyanosis and 
often a profuse perspiration. The respiratory move- 
ments are limited and dyspnea is present even when 
the patient is quiet. 

Palpation: — There is fullness of the interspaces 
with diminution of movement. 

Percussion: — This reveals either an unilateral 
or a bilateral flatness. 

Auscultation: — This confirms the findings of 



HYDROTHORAX. 247 



percussion but does not reveal friction sounds or 
other evidences of inflammation. 

Diagnosis : — This is based upon the presence of 
one or more diseases sufficient to produce the dropsy, 
together with the fact that there is no fever, pain, 
nor other symptoms that are characteristic of 
pleurisy with effusion. 

Prognosis : — This is dependent upon the origi- 
nal disease, as the appearance of hydrothorax is 
but an indication that the disease is advancing, and 
must always be looked upon as an unfavorable 
sign. 

Treatment: — While the attention should be de- 
voted to the primary disease, yet in cases at least 
of a failing cardiac power it will be found that 
drainage by the insertion of several hypodermic 
needles in the legs, and by paracentesis will give 
the heart an opportunity to regain its strength and 
allow the remedy given to act more favorabl}'. 
The remedies that should be studied are arsenicum, 
apocynum, apis, digitalis, jaborandi and elaterium. 



CHYLOTHORAX. 

Synonyms — Chylous pleurisy. 

Definition: — This is a collection of chyle in the 
pleural cavit}'. It may take the form of a ch3'lous 
ascites when it is found in the abdominal cavity as 
well as the pleura. 

Etiotogy : — In the majority of cases it results 
from an occlusion . of the thoracic duct at its en- 
trance into the left subclavian vein, due to a nar- 



248 CHYLOTHORAX. 



rowing, thickening, thrombosis, new growth, or 
tuberculosis. It may resuh from a rupture of the 
duct. 

Pathology : — Many of the recorded cases show 
a constriction at the entrance of the duct into the 
left subclavian vein, the duct as well as the lym- 
phatic of the lungs pericardium and pleura being 
distended. In those cases that are the result of 
rupture of the duct the lymphatics are not dis- 
tended. The fluid may be found in both cavities. 
It contains fat, albumen, globulin and inorganic 
salts. 

Symptoms: — Many of the symptoms are due 
to the primary lesion, as the effusion does not 
modify them to any extent. Emaciation is not 
marked except in those cases where it would 
naturally be expected, as in cancer or tuberculosis. 
The dyspnea and pain are often marked. The 
pulse is but slightly accelerated. The temperature, 
if elevated, is but little above the normal. 

The physical signs are those of a pleural effu- 
sion. 

Diagnosis : — This is dependent upon the physical 
signs of effusion and the results of exploratory tap- 
ping, together with the absence of a history of 
pleurisy and a temperature that is but little if any 
above the normal. This condition should not be 
mistaken for a chyliform effusion, the result of a 
fatty metamorphosis of the cellular elements of an 
ordinary sero-fibrinous, or purulent effusion. 

Prognosis : — This is unfavorable. The duration 
of the disease is from six to nine months. Anas- 
tomosis with the right duct may take place in 
slowly developing cases. 



NEW GROWTHS OF THE PI.EURA. 249 

Treatment: — This consists in repeated tapping 
and the meeting of the symptoms as they arise. 



NEW GROWTHS OF THE PLEURA. 

These may be primary or secondary. When 
primary they are in the form of fibroma, sarcoma, 
and endotheHal, all of which are rare, while the 
secondary forms are extensions from the surround- 
ing tissues and are either sarcomatous or cancerous. 
The organ primarily involved may be in any part 
of the body but most frequently it is the lungs, 
mediastinum, chest wall, or breast. 

The duration of tumors of the pleura are from 
two to three months or from one to two years. 
When primary their course is rapid, terminating in 
a few months. Like new growths in other parts 
their onset is insidious. Pain, while a prominent 
feature in some cases, is usually slight or wholly 
absent. There is more or less malaise, loss of 
strength, loss of flesh, with the presence of a cough 
^nd dyspnea, especially upon exertion. 

There is but little fever present unless there is 
some compHcation. The urine contains albumen; 
there is some edema about the ankles accompanied 
with attacks of vomiting and gastric derangement. 
There is usually some rounding or fullness of the 
chest indicating the growth. The heart may or 
may not be displaced, and the vocal fremitus may 
be disminished. 

The growths are most frequently mistaken for 
pleurisy, but they are of slow development and do 
not show the pain and fever of the latter. 



250 NEW GROWTHS OF THE PLEURA. 

The removal of the effusion attending the new 
growth does not remove the dullness as it does in 
pleurisy. In some of these cases the effusion is 
hemorrhagic. 

It is often difficult to make a positive diagnosis 
in primary cancer of the pleura, while in secondary 
cancer its presence m other organs and the cancer- 
ous cachexia will assist. 

The prognosis is grave. 

The treatment is symptomatic. Unless there 
are marked indications for it the effusion should not 
be removed, as its removal gives no relief. In many 
cases it speedily reaccumulates, and in others its 
removal is attended with great dyspnea. 



CHAPTER XXVII. 
PULMONARY TUBERCULOSIS. 



Synonym: — Pulmonary phthisis; consumption. 

Definttzon: — This is an infectious disease caused 
by the tubercle bacillus characterized by cough, 
fever, sweats, emaciation, and a purulent expectora- 
tion that contains fibres of degenerated lung tissue 
and the tubercle bacilli. 

Varieties: — I. Chronic ulcerative tuberculosis; II. 
acute phthisis; III. fibroid phthisis. 

CHRONIC ULCERATIVE TUBERCULOSIS. 

Etiology : — That the tubercle bacilli may be 
transmitted directly from the patient to the offspring 
has been demonstrated by detecting them in the 
young calves of cows known to be tubercular; also 
found in the human fetus removed by Caesarian sec- 
tion from tubercular mothers. Apart from this 
direct transmission there may be an inherited pre- 
disposition characterized by a deficiency in the 
germicidal and defensive properties of the tissue, 
and an inherited weakness of the respiratory organs, 
lymphatic and vascular systems which favor the 
localization of the germs. 

Out of looo cases collected in one series there 
was a family histor}^ of tuberculosis in 388 cases, 
while 81 per cent of the cases showed a family 
weakness in some particular, either phthisis, syphilis, 
or malignant affections. While this predisposition 
may be from both parents, it is more frequently 



252 PULMONARY TUBERCULOSIS. 

traced to the mother than to the father. It may 
be acquired. Statistics show that those who are 
given to the excessive use of alcohol are apt to 
develop tuberculosis, and especially those who spend 
much of their life in sedentary employment, where 
there is a tendency to stoop and thus restrict the 
natural expansion of the lungs. 

Occupation is an active cause, at least those 
occupations that necessitate breathing a vitiated 
atmosphere, one laden with particles of dust that 
cause pulmonary irritation. Sudden changes in the 
temperature resulting in chilling of the body are 
injurious; also lack of sunshine with abundant 
moisture in the atmosphere, if associated with a low 
altitude and wet subsoil. There is no doubt that 
many cases, attributed solely to hereditary predis- 
position, have been hastened by the mode of living 
of the individual, while others with this tendency 
have escaped by living under such favorable en- 
vironments that the resistance of the system has 
been increased, and the disease thwarted. 

This disease is found among all races, being less 
prevalent among the Jews than among other races; 
with negroes the death rate is high. It is more 
prevalent in the cities than in the country. This 
increased prevalency in cities is dependent on over- 
crowding, bad ventilation, dark rooms, an excess of 
dust, living in apartments with defective sewerage, 
and where persons suffering with tuberculosis have 
resided before. It is doubtful if the germs are ever 
eradicated from such a place. The health of any 
one may be so impaired that the resisting power of 
the system is not sufficient to overcome an infection 
by the germs of this disease. Frequent child-bear- 



PULMONARY TUBERCULOSIS. 253 

ing and prolonged lactation are often predisposing 
causes. There is practically no difference in the 
susceptibility of sexes to pulmonary tuberculosis. 

During the first five years of life the death rate 
is equal among the sexes, from live to thirty-five 
there are more females than males, while after this 
period the rate is much higher among males. Cer- 
tain diseases, such as pleurisy, bronchial catarrh, 
pneumonia, disease of the cardiac valves, especially 
stenosis of the pulmonary orifice, diabetes, cancer, 
syphilis, and various neuroses are often followed by 
tuberculosis. Many cases are the result of infection 
from food, especially milk and meats; in these 
cases the lungs are involved secondarily. 

Pathology : — In its incipiency tuberculosis is a 
local disease, dependent upon the lodgment and 
development somewhere in the body of the tubercle 
baciUi; from this point the process extends both by 
continuity and contiguity of tissue. The bacillus 
g^ins entrance into the lung either through the 
lymphatic system, a blood vessel, or by aspiration 
from an already infected area. When of lymphatic 
origin they develop near the original foca, while if 
they are conveyed by the blood they are scattered 
through the lung evenly. 

When the infection takes place through the 
blood current, the bacilli are arrested in the alveolar 
capillaries, where there is a cellular growth, which 
early extends from the capillary walls to the cavity 
of the air sac, where the cell growth is continued. 
In those cases where the microbe enters the lunor 
by the air passages, it is arrested in the bronchi or 
alveoli; if it becomes deposited in the former it 
pierces the peri-bronchial sheath, and gives rise to 



254 PULMONARY TUBERCULOSIS. 

peri-bronchitis; if in the latter it gives rise to a 
broncho-pneumonia. 

The tubercle bacilli, having gained entrance into 
the tissue, multiply, and by producing proliferation 
of the nuclei, and division of the protoplasm, lead 
to the production of cells in the surrounding tissue, 
which resemble epithelial cells, and hence are called 
epitheloid cells. The changes take place in the 
epithelial elements and endothelial cells of the 
capillaries, as well as in the cells of the connective 
tissue. Either as the result of the multiplication of 
the nuclei in a single cell, or from a fusion of in- 
dividual cells, giant cells are formed. The leuco- 
cytes leave the surrounding vessels, and, arranging 
themselves about the giant cells, complete the 
group of cells entering into the tubercle. In the 
early stages, the epitheloid cells contain the bacilli 
in their interior. 

As the tubercle becomes more pronounced and 
larger, a reticulum appears, the margin of which 
becomes well defined as the pressure from within is 
increased. As a result of these changes the blood 
supply is gradually cut off, and either caseation or 
fibrosis of the tubercle results. In the former, the 
cellular elements occupying the center of the tuber- 
cle become swollen, lose their nuclei, and are fused 
together, forming a structureless mass which under- 
goes fatty degeneration, assuming a yellow color. 
This mass may then soften, its capsules rupture, 
and its contents be discharged; or lime salts may 
be deposited, and it then becomes calcareous in 
nature. 

In fibrosis, the tubercle does not become caseous, 
but owing to an over-growth of the connective tis- 



PULMONARY TUBERCULOSIS. 255 

sue elements and a further development of fibroid 
tissue within the tubercle and neighboring struc- 
tures, the whole mass is transformed into a firm 
fibroid nodule. This latter process is considered an 
indication of greater resistance on the part of the 
tissue. 

Should the process be one of acute miliary 
tuberculosis, the patient does not survive long 
enough to allow the tubercle to go through all of 
the changes that occur where the lesion is localized, 
and the process more chronic. The first lesion is 
usually one or two inches below the apex of the 
lung. It may, however, have its primary seat at 
some other point. The explanations given as to 
why the apex should be the portion of the lung 
first attacked have been many and various. Prob- 
ably the narrow range of movement of the chest, 
dependent upon the limited motion of the ribs of 
this part; the open condition of the bronchi of this 
part of the lung, and the less vigorous circulation 
of the apex, combine to favor this location. It is 
often nearer the posterior than the anterior border. 
This explains why, in some cases, by careful ex- 
amination evidence of the disease is first found in 
the supra-spinous fossa. 

When the lower lobe is involved it is at a point 
below the apex, corresponding to the fifth dorsal 
spine; from this point the disease spreads along the 
line of the interlobular septa, which is indicated by 
the vertebral border of the scapula, when the hand 
is placed upon the opposed scapula, and the elbow 
raised above the shoulder. The period elapsing 
between the involvement of the first and second lung 
is not definite, but the apex of the lower lobe of 



256 PULMONARY TUBERCULOSIS. 

the first lung attacked is usually involved before 
the second lung is implicated. The lesion may be 
primary at the base of the lung, but this is rare; 
in some cases the process is arrested in the apex 
and continues at the base. 

In the early stages of chronic ulcerative phthisis, 
the essential element is the miliary tubercle which is 
near the apex, and is connected with a small bronchi 
or air cell; in time the tubercles coalesce and, 
breaking down, form cavities. 

Patches of pneumonia are found scattered through 
the lung in cases of chronic phthisis. These may 
be broncho-pneumonic in character. The exudate 
in the beginning may be muco-purulent, fibrinous, 
fibrino-purulent, or gelatinous; later the mass as 
well as the consolidated lung tissue surrounding it 
becomes caseous. In some cases these areas 
soften; this is due either to action of the tubercle 
bacillus, or to a secondary infection with pus organ- 
isms. In cases that are decidedly chronic, a fibrous 
pneumonia is established about the caseous mass. 
A fibrous capsule surrounds the diseased area, after 
which the fluid is absorbed, leaving a dry, firm, 
and friable nodule, in which lime salts may be 
deposited, rendering it calcareous in character. 

The cavities met with in chronic phthisis are 
either bronchiectatic or ulcerative in kind. The 
former are met with in connection with medium- 
sized and small bronchi and vary in size from the 
smallest possible, to those the size of a hen's Qgg. 
They may be fusiform, sacculated, or globular in 
shape. The walls of these cavities are bronchial 
in origin, but the ulcerative process may extend 
beyond and involve the lung tissue. In the latter 



PULMONARY TUBERCULOSIS. 257 

form the ulcerative process may result from an ex- 
tension of the bronchiectasis, or it may be due to 
the breakincr down of a tuberculous mass within the 
lung. 

The cavity may go on enlarging until it in- 
volves the whole lobe, or lung. In both forms 
the cavities are more common near the apex of 
the lung. The appearance of the cavities varies, 
according as the process is acute or chronic. In 
the acute form the walls are irregular, indefinite, 
and surrounded by necrotic lung tissue and caseous 
material. The chronic form has a definite wall 
composed of dense, fibrous tissue, the result of an 
interstitial pneumonia. Within this framework is 
a layer of granulation tissue which often contains 
the tubercle and shows caseation, while across the 
cavities extend trabeculae in different directions, 
accompanied by blood vessels; some of these 
become obliterated, while others losing their 
natural support, form aneurysms which may rupture 
and give rise to the profuse hemoptysis that occurs 
during the later stage of the disease. The cavities 
increase in size by ulceration of their inner walls. 
Their contents consist of broken down lunor- tissue, 
pus and blood. In the decidedly chronic cases 
the cavities are surrounded by such dense fibrous 
walls that the ulcerative process may be controlled 
and the cavities partially obliterated, due to a con- 
traction of the fibrous tissue. 

The pleura is more or less involved in all cases. 
In the acute form, a sero-fibrinous exudate is fre- 
quently present. It may be tubercular in origin, 
and yet not show the presence of the tubercles; 
but they will usually, but not always, be found if 



258 PULMONARY TUBERCULOSIS. 

careful search is made. There are adhesions in 
all cases with a partial or total obliteration of the 
pleural sac. In the chronic form the pleurisy is 
more localized and bands that become very dense 
and firm are formed. 

The bronchi show marked changes; and^ while 
the early development of the case is usually in 
the smaller tubes, the larger ones are the seat of 
inflammatory changes, that may in time extend so 
deeply as to involve the bronchus and lead to 
dilatation. 

The bronchial glands are involved in all cases. 
There may be but one, or the whole group may 
show involvement, and be converted into one 
dense caseous mass. They may soften, and the 
abscess discharge into a bronchus, the oesophagus, 
the trachea, or a blood vessel. The other organs 
may show a secondary involvement, or amyloid 
degeneration; there are bone changes, the result 
of the absorption of toxines. 

Symptoms: — The appearance of chronic tuber- 
culosis is manifested in a variety of ways, but 
usually there are certain constitutional symptoms 
that announce its appearance. These symptoms 
may appear at times insidiously, and may be in 
form of an anemia or a functional derangement of 
the digestive system accompanied by a slight 
evening rise of temperature, a loss of flesh and 
strength. A catarrhal bronchitis may be present 
or a condition with a cough wuth an expectoration 
which passes for a simple bronchitis, but in a 
short time a slight fever appears during the after- 
noon and there are other constitutional symptoms 
that leave no doubt as to the real disease. 



PULMONARY TUBERCULOSIS. 259 

If careful inquiry is made it will frequently be 
found that the health has not been quite up to the 
normal for some time. This ill-health may date 
from an attack of influenza or some other acute 
disease. In other cases the first symptom is a 
pleuritic pain; the process may be plastic or sero- 
fibrinous in character; with it there may be the 
typical fever and the other symptoms of the dis- 
ease may appear and increase to an unfavorable 
termination. All indications of pleurisy may dis- 
appear and temporary recovery take place, but it 
is of short duration, for soon the symptoms return 
with renewed vigor and every indication of pulmo- 
nary tuberculosis is present. In another case the 
first indication is hemoptysis. At times the larynx 
is the first to be involved, when it is indicated by 
a hoarseness with aphonia and hyperaesthesia or 
parsesthesia of the throat. 

Early in the involvement of the lungs a cough 
with expectoration, shortness of breath, pain 
about the chest, and hemoptysis appears. At its 
first appearance the cough is dry and hacking in 
character and is often worse after retiring and 
again early in the morning. There is but little if 
any expectoration present at this stage, as the 
cough is more irritative in character and may be 
much aggravated during eating, at which time it 
may cause retching and vomiting. In adults the 
cough is seldom paroxysmal in character, but in 
children with enlarged bronchial glands it often 
assumes this type. In patients that are of a nerv- 
ous temperament the cough may be a very 
troublesome feature of the disease through all the 
stages, although in the more sluggish it may 
cause but little annoyance. 



26o PULMONARY TUBERCULOSIS. 

As the disease advances and softening of the 
tubercles take place the cough becomes easier 
and the expectoration more profuse. It is 
more marked early in the morning, and as the 
fever appears later in the day the cough may be 
again annoying. As the late stages of the disease 
are reached it usually becomes painful and assumes 
more of the paroxysmal type, yet in some cases 
this may not appear. The cough is aggravated 
by lying on the painful side. 

In the early stages the cough is dry, and not 
enough sputum can be secured to make a micro- 
scopical examination. But usually there is a small 
amount expectorated with the early morning 
cough which may contain yellow streaks or opaque 
spots. As the softening advances there is less 
mucoid and frothy material, and more of the pur- 
ulent expectoration. When cavities are present 
the expectoration is in the form of rounded masses 
of a greenish gray or ashy gray color. The odor 
is stale, but may be sweetish or fetid. Should 
the lung be breaking down rapidly the expectora- 
tion is profuse and contains a cheesy material. 
At times the expectorated material resembles 
boiled sage. This is also met with in bronchitis 
and is not characteristic of tuberculosis. 

Although these patients show an increased 
frequency of respiration, especially noticeable 
towards evening and on exertion, they seldom 
complain of dyspnea except in the late stages of 
the disease. The reduction in the volume of 
blood and the gradual appearance of the pul- 
monary disease have been looked upon as explain- 
ing the absence of the subjective sensation of 




PHYSICAL SIGNS DURING THE EARLY STAGE OF TUBERCULOSIS. 



262 PULMONARY TURERCULOSIS. 

dyspnea. In those cases where other chronic con- 
ditions appear dyspnea is often a marked symptom. 

These cases do not advance very far before the 
patient complains of pain in the chest, usually in 
the axillary or mammary region. It may be a 
mere sensation of pain or it may be stitching or 
agonizing, and attended with tenderness on percus- 
sion. In the cases where cavities have formed 
there may be a dragging pain due to stretch- 
ing of the parietal pleura and intercostal nerves. 
These pains must not be mistaken for the rheu- 
matic pains that are found about the chest wall in 
some patients, nor the general tenderness that is 
observed on percussion of cachectic subjects. 

The appearance of an afternoon elevation of 
temperature is an important symptom. The fever 
may be preceded by a slight shivering, but sel- 
dom does it amount to a marked rigor. The fever 
is highest between 2 and 10 p. m., and the low- 
est from 2 to 8 a. m., yet it may be reversed, 
but it is always either remittent or intermittent in 
character. When intermittent it ranges from 
slightly sub -normal in the morning to 102° or 
103° toward evening, but there may be a variation 
of from 8 to 9 degrees. Whenever the range of 
the temperature is great and the morning readings 
are low, there is profuse perspiration and the type 
of fever resembles that of the hectic fever of 
pyemia. When the fever assumes the remittent 
type it indicates that an active tubercular infiltra- 
tion is taking place, or that an intercurrent dis- 
ease is appearing. While fever is not always 
present during a case of tuberculosis yet it is a 
reliable guide to the activity of the disease. 



PULMONARY TUBERCULOSIS. 263 

Although not holding any definite relation to the 
fever profuse perspiration is generally met with in 
all of these cases. It is most marked during the 
early hours of the morning when the fever is 
lowest, but may be present at any time. It is 
most prevalent in those cases where excavation in 
the lung tissue is taking place and suppuration is 
marked. • 

The digestive system suffers. At the onset of 
the disease there is loss of appetite, with thirst, 
and indications of gastric catarrh, yet if the pa- 
tient can eat he is usually able to digest the food. 
The tongue is often covered with a thin white 
fur; when the gastric symptoms are more pro- 
nounced it then has a thick coating, and the 
mucous membrane of the mouth becomes red and 
irritable. Should the digestive organs be atonic 
the tongue will be broad, flabby, and takes the 
imprint of the teeth. Later when the fever is 
high and ulceration of the intestines is present 
the tongue becomes red, raw, dry and fissured. 
Vomiting may be an annoying symptom in 
many cases after coughing or the taking of food. 
Diarrhea is present when the large intestines are 
involved and ulceration of the intestinal mucous 
membrane has resulted. Intestinal hemorrhage is 
rare, but may take place as a result of the ulcer- 
ation. 

One of the most constant and important symp- 
toms is emaciation. In the acute cases it may not 
be as marked as it is in the chronic. The rapidity 
with which the flesh is lost bears a definite rela- 
tion to the fever. The weight may increase some- 
what while a slight fever is present, providing the 



264 PULMONARY TUBERCULOSIS. 

appetite is ^ood, the supply of food sufficient, and 
the digestion and assimilation normal. In those 
cases where emaciation appears and progresses 
before any elevation of the temperature is present, 
the toxines of tuberculosis may be the cause. Any 
derangement of the stomach or bowels which 
interferes with the digestion or assimilation will 
lead to emaciation, weakness, and debility, often 
out of all proportion to the other evidences of the 
disease. 

The pulse becomes rapid, of a low tension, and 
usually small Its rapidity often bears a direct 
relation to the activity and extent of the disease. 
It is more rapid towards evening. An easily ex- 
cited heart's , action or a constant high pulse rate 
is an indication of incipient tuberculosis. 

The patient is extremely sensitive to slight 
variations in the temperature, often complaining of 
coldness of the extremities. When there are pro- 
nounced cardiac complications cyanosis may be 
marked. 

The appearance of the skin varies; in some 
cases it is thin, delicate, and oily, the complexion 
being transparent, while in others it is of a dirty, 
branny appearance. 

There are no definite blood changes; the red 
blood corpuscles are usually normal; the hemoglo- 
bin is slightly diminished; the leucocytes undergo 
no change in character, while the leucocytosis in- 
creases with softening of the tubercular foci. 

Hemoptysis is observed in about 70 per cent, 
of all cases, being more frequent in males than 
females, and in young adults rather than at the 
extremes of life. The amount of blood brought 







PHYSICAL SIGNS IN THE MORE ADVANCED STAGE OF TUBERCULOSIS 



266 PULMONARY TUBERCULOSIS. 

up at one time may vary from a drachm to a pint. 
In the great majority of cases it recurs from time 
to time. During the early stages it is usually a 
small amount and seldom fatal, and is the result 
of softening of the bronchial mucous membrane. 
Later when cavities have formed the bleeding is 
more profuse, and while it may prove fatal this is 
not the rule excepting in the last stage of the dis- 
ease, when an aneurysmal dilatation of a large ves- 
sel may rupture. The hemorrhage appears sud- 
denly, coming with a slight cough, or the patient 
may simply recognize the warm, salty taste in the 
mouth, and upon expectoration find it to be 
blood. At times a fatal hemorrhage may take 
place without any blood being seen, a large cavity 
retaining all of it. 

A microscopical examination of the sputum 
shows that the chief portion of the muco-purulent 
sputum consists of pus cells, together with epi- 
thelial cells from the mouth, pharynx, trachea, 
bronchi and alveoli. Elastic tissue, when forming 
a part of the sputum, indicates that there is de- 
struction going on in the air passages or lungs; 
this is present, not in tuberculosis alone, but in 
all conditions of softening, as gangrene, abscesses, 
etc. The presence of the tubercle bacillus in the 
sputum enables the physician to make a positive 
diagnosis at an early stage, even before the physi- 
cal signs would warrant such a statement. They 
should be sought for in the grayish yellow streaks 
of purulent sputum, and may be demonstrated in the 
expectoration in cases of hemoptysis. While the 
process is rapidly advancing and there is much 
destruction of tissue the bacilli are numerous, but 



PULMONARY TUBERCULOSIS. 267 

cases will be met with in which the process is ad- 
vancing and yet but few if any will be found in 
the sputum, although other forms of micro-organ- 
isms will be present in abundance. 

Occasionally calcareous fragments are coughed 
up varying in size from that of a pea to that of 
a cherry, and of which there may be one or more. 
They are formed from the calcification of caseous 
masses in the lungs or from the bronchial glands. 

PHYSICAL SIGNS OF THE INCIPIENT STAGE. 

Inspection: — Frequently this shows a dilated 
non-paralyzed pupil. The nutrition may not be 
much affected and the color may be normal, the 
chest may be seen to be flat or "alar" in shape. 
There may be no change in the respiratory expan- 
sion, but in some cases by standing behind the 
patient a slight deficiency in the expansion of one 
apex will be noticed. The chest is often seen to 
be short in the anterior-posterior diameter. The 
intercostal spaces are wide, the shoulders are 
stooping, the scapulae are wing-like, and the ver- 
tebral column is convex posteriorly. If the case 
has passed along to the first stage a fine network 
of veins will be observed under the skin over the 
upper lobe of one or both lungs. 

Palpation: — This and mensuration may not 
bring much assistance; in some cases there is an 
increased pulse rate and a deficient respiratory 
expansion at the apex of one lung. Vocal fremi- 
tus may be increased over the diseased lung. 

Percussion: — This usually does not reveal any- 
thing definite. In some cases there will be found 



268 PULMONARY TUBERCULOSIS. 

an area of impaired percussion-resonance, usually 
in the upper portion of but one lung. 

Auscultation: — The vesicular murmur is altered, 
inspiration becomes less soft and breezy, and is 
jerky and arythmic, while expiration is prolonged 
and high pitched. By careful attention just at the 
close of inspiration, fine moist rales, or a sense 
of stickiness may be detected, while vocal reson- 
ance is increased. 

SECOND STAGE, OR STAGE OF CONSOLIDATION. 

Inspection: — Pallor and emaciation now be- 
come marked symptoms. The lips are red, a hec- 
tic flush appears on the cheeks, the superficial 
veins become more prominent, there is retraction 
in the supra- and infra-clavicular regions during 
inspiration. The respirations are increased in fre- 
quency, are superficial, and accompanied with a 
tendency to cough on deep inspiration. The upper 
portion of one side of the chest is seen to be flat 
and the expansion deficient. 

Palpation: — This shows an increase in the 
pulse rate, the skin is hot and dry or it is bathed 
in perspiration. There is a diminution of the 
respiratory movements while the vocal fremitus is 
increased over the consolidation except in those 
cases where the pleura is very much thickened 
over the area involved. 

Percussion: — As the consolidation appears dull- 
ness is observed over the affected part. During 
the early stages it may be necessary to have the 
patient take a full inspiration and hold the breath 
while percussion is being practiced that any changes 



PULMONARY TUBERCULOSIS. 269 

in the apices may be noticed. If the consolidation 
is deep it may not be recognized by percussion. 

Auscultation: — Inspiration is prolonged and 
blowing, or the breathing may be wholly bron- 
chial. The vocal fremitus and resonance are in- 
creased. Rales, both large and small, dry and 
moist, are present, while friction sounds depend- 
ent upon circumscribed pleurisy may be present. 

THIRD STAGE, OR THE PERIOD OF THE FORMATION OF 

CAVITIES. 

Inspection: — There is a general emaciation with 
marked depression above and below the clavicle, 
and the face is haggard, with indications of cyano- 
sis. The ribs are prominent, the interspaces are 
narrow, the respiratory movements are limited, 
there being but little movement of the affected 
part, and on forced inspiration the chest appears 
to be anchylosed. 

Palpation: — The pulse is now small, feeble, 
compressible and rapid. Increased vocal fremitus 
is present, providing there is an empty cavity that 
communicates with a bronchus, while friction 
fremitus is often noticed. 

Percussion: — Dullness is noticed in a varying 
degree in the upper lobes of the lung. This dull- 
ness gives way to resonance- over a cavity, which 
may be amphoric or cracked-pot when the cavity 
communicates with a bronchus. At times even a 
large cavity may give a dull percussion note when 
the mouth is open. If the cavity is small or 
deeply located it may not be recognized on per- 
cussion. In cases where there is little or no pleu- 



270 PULxMONARY TUBERCULOSIS. 

ritic thickening there may be numerous small cavi- 
ties at the apex that do not change the percussion 
resonance. 

Auscultation: — When the cavities are larger 
and freely communicate with a bronchus, the res- 
piration is soft, blowing, or puffing in character. 
Expiration is low pitched and prolonged. When 
the cavities are small and surrounded- with a large 
amount of consolidation the respiration is broncho- 
cavernous in character. 

Rales, either gurgling, moist, or dry, may be 
present. In the majority of cases of phthisis signs 
of the three stages may be found at different 
points of the lung at the same time. 

Diagnosis: — When a case is well advanced 
there is but little difficulty in arriving at a correct 
diagnosis, as the presence of the bacilli and elas- 
tic tissue in the sputum are always characteristic, 
while the cough, fever, progressive emaciation, 
and physical signs, as flattening of the chest, defec- 
tive expansion, dullness of the percussion note, 
and alteration in the vesicular murmur form a 
group of symptoms that are characteristic. The 
diagnosis should always be made as early as pos- 
sible that the disease may not gain inroads upon 
the system. In cases where the sputum is scanty, 
the tubercle may not be found, and repeated ex- 
amination must be made before its presence is 
demonstrated. When hemoptysis appears it should 
call forth a most careful examination of the case 
lest a latent tuberculosis be stealing on. 



PULMONARY TUBERCULOSIS. 



271 



PULMONARY SYPHILIS. 

1. The middle and lower por- 
tion of the lung is most in- 
volved 

2. The gummata or fibroid in- 
duration is localized. 

3. History of syphilis. 

4. No bacilli in the sputum. 

BRONCHIECTASIS. 

1. Is slow if at all progres- 
sive. 

2. Sputum contains no tubercle 
bacilli. 

3. Cavities most marked at 
the base. 

4. Cavities precede consolida- 
tion. 

5. Usually bilateral from the 
start. 

ABSCESS OF THE LUNGS. 

Develops during the course of 
pneumonia, emphyema, or 
as a res lit of traumatism or 
general pyemia. 

1. Usually in a lower lobe, 
and on one side only. 

2. An acute condition. 

3. Sputum does not contain 
the tubercle. 

4. Physical signs circum- 
scribed. 

MALARIAL FEVER. 

I. There are plasmodia in the 
blood. 



PULMONARY TUBERCULOSIS. 

1. The upper portion of the 
lung is first involved. 

2. The process is diffused and 
irregular. 

3. Constitutional manifesta- 
tions of tuberculosis. 

4. Tubercle bacilli are present. 

PULMONARY TUBERCULOSIS. 

1. Usually gradually progres- 
sive to a fatal termination. 

2. Contains them. 

3. Most at the apices. 

4. Consolidation precedes cav- 
ities. 

5. Usually unilateral at first. 

PULMONARY TUBERCULOSIS. 



1. Usually in the upper lobe 
of one lung at first, and on 
both sides later. 

2. A chronic condition. 

3. Contains the tubercle. 

4. More diffused. 

PULMONARY TUBERCULOSIS. 

1. Are not present. 



272 PL'LMONARY TUBERCULOSIS. 

MALARIAL FEVER. PULMONARY TUBERCULOSIS. 

2. Sputum does not contain 2. Contains them, 
tubercle bacilli. 

3. Breathing is normal. 3. Persistent dyspnea; respi- 

rations are increased in fre- 
quency. 

4. Sweats ; not always at 4. Night sweats. 
night. 

5. Percussion and ausculta- 5. Dullness and mucous rales 
tion normal. present. 

Co7nplications : — These are principally the result 
of a direct or secondary infection. In the first the 
trachea, larynx and pharynx are directly inoculated, 
while in the second infection is carried by the 
blood to distant organs. The larynx is involved 
in from 25 to 50 per cent, of all cases. Its early 
indications are those of a chronic laryngitis, with 
hoarseness, tickling, and a sense of fatigue on 
using the voice, severe pain if the epiglottis is in- 
volved, and stenosis from a mechanical fixation of 
the cords, the result of infiltration about the crico- 
arytenoid joint may result. 

The bronchial glands are usually involved in the 
tubercular process. The groups most frequently 
implicated are the pretracheal and subtracheal. At 
times in children the enlargement may be to such 
a degree that it causes obstruction to the bronchi 
or trachea. One of these enlarged glands may 
press upon the recurrent laryngeal nerve, giving 
rise to paralysis of the vocal cord, the left being 
the one most frequently involved. They may 
suppurate and discharge into the trachea, causing 
fatal asphyxia, or into a bronchus leading to sep- 
tic broncho-pneumonia. When the first evidence' 



I 



PULMONARY TUBERCULOSIS. 2 73 

of the disease is in a bronchial gland it may be- 
come calcified, and the disease arrested. 

Pneumo-thorax is always a serious and often a 
fatal complication. 

Pleurisy is present in every case; whether there 
are any indications of it during life or not post 
mortem examinations will reveal it. It may be of 
the dry variety or there may be an effusion which 
is sero-fibrinous, purulent or hemorrhagic in char- 
acter. When the exudate is purulent it always ren- 
ders the prognosis of the case grave, as absorption 
is not to be looked for and treatment by incision 
is not successful. 

Pneumonia of the croupous type is often met 
with, while that of the broncho-pneumonic type is 
but an acute exacerbation of the disease. 

The heart is small and may show atrophic 
changes, fatty degeneration or tubercular masses; 
these, however, seldom give rise to functional dis- 
turbances. A dilatation of the right ventricle 
occurs if there is much interference with the pul- 
monary circulation. The endocardium is seldom 
involved, while the pericardium shov/s involvement 
as the result of the extension of the disease from 
the pleura, peritoneum, or anterior mediastinal 
glands. 

The alimentary canal shows infection in many 
of these cases. Tubercular ulceration of the lips 
is rare; the tongue is more frequently involved, 
and here, and at other parts of the mouth, the 
lesion may be mistaken for syphilis or malignant 
disease. The esophagus shows these lesions at 
times, but the stomach is seldom involved; while 
the intestines are more frequently affected than 



274 PULMONARY TUBERCULOSIS. 

any of the other organs. Seventy per cent, of 
the cases show intestinal ulceration. When the 
ulceration is most marked in the large bowel diar- 
rhea becomes very aggravating, although there 
may be marked ulceration of the ileum without any 
diarrhea. 

Anorexia is frequently an early symptom, when 
there may be pronounced loathing of all food, 
while later in the disease there is nausea and 
vomiting. 

The nervous system presents certain symptoms 
that show its involvement, as aphasia from menin- 
gial tubercles along the fissure of Sylvius. Basilar, 
or cerebro-spinal meningitis may result from it. 
The mental condition is one of cheerfulness, the 
patient planning for future events when dying. 
The urine presents no definite change except when 
the fever is present. Pus, when present in the 
urine, is the result of disease of the bladder, pelvis 
or kidneys. 



CHAPTER XXVIII. 
PULMONARY TUBERCULOSIS. 

(CONTINUED.) 



Prognosis: — There is possibly no disease that 
demands a niore thorough acquaintance with its 
every phase before giving a prognosis than does a 
case of pulmonary tuberculosis. Observations made 
at autopsies lead us to believe it to be the most 
curable of all chronic diseases, that it is not neces- 
sarily fatal, that many cases are arrested during 
their early stages; but that in itself it is not a self- 
limited disease. 

The stage of the process in each case must 
always be taken into consideration, as in those 
where recovery has taken place it has been during 
the stage of infiltration. For while it is not impos- 
sible for complete cicatrization and obliteration of a 
cavity to take place, yet in a proportion of the 
cases in which physical examination gives signs of 
a cavity they are due to a development around the 
caseous mass of a fibrous capsule. In those cases 
where arrest of the process takes place after cavities 
have formed death is usually the result of a light- 
ing up of the tubercular process at some point later 
in life. When during the early stages of the dis- 
ease it appears to be pursuing an acute course, and 
when the necrotic tissue' is evacuated there is either 
a complete arrest of the disease or temporarily a 
general improvement of the case. The immediate 
and remote effects and the progress of the disease 



276 PULMONARY TUBERCULOSIS. 

in each case should be thoroughly investigated. 
When after but a short duration it is located in 
the upper part of the lower lobe it should be 
recognized that the process is rapid and that the 
prognosis is correspondingly unfavorable. When 
but one lung is affected the condition of the other 
should be carefully investigated, and if found to be 
enlarged, with signs of increased activity, the indi- 
cations are more favorable. If there are early 
indications of involvement of both lungs the infer- 
ence is that the course of the disease will be rapid 
and the termination unfavorable. 

Fever is the most important of the general 
symptoms. The range of the temperature should 
be observed over an extended period before giving 
an opinion based upon it. In chronic cases a con- 
tinued high temperature is always unfavorable as it 
indicates the involvement of a part of the lung 
hitherto exempt from the process; an increase in 
the temperature indicates a renewed activity of the 
disease and may prove uncontrollable. While ab- 
sence of the fever with abatement of all the other 
symptoms is always to be considered favorable, a 
low temperature may be dependent upon a condi- 
tion of exhaustion. A continuously rapid pulse, and 
one that is easily excited, should always be looked 
upon as indicating debility or nervous erethism 
which with emaciation and anemia are unfavorable. 

The amount of dyspnea should be considered as 
depending upon the involvement of the pulmonary 
tissue. The expectoration should be taken into 
consideration. If it is scanty or moderate in quan- 
tity this is to be considered a favorable sign, but it 
should be ascertained whether or not it is being 



PULMONARY TUBERCULOSIS. 277 

swallowed as is the case with some women and 
children. Neither the amount of tissue destruction 
taking place at any particular time, nor the number 
of the tubercle bacilli is to be looked upon with 
any great significance in the prognosis. 

There is not much importance to be attached 
to the odor of the expectoration except in those 
cases where it indicates a septic broncho-pneumonia 
or gangrene. When the cough is incessant and un- 
controllable, so that it interferes with sleep and 
causes vomiting it then becomes an element in the 
prognosis. The state of the digestive organs and 
the appetite are often of the greatest importance, 
for as long as they are good there will be periods 
of quiescence in the disease when an opportunity 
will be given to improve the general condition of 
the patient; on the other hand should the digestion 
be poor and the assimilation faulty the prospect for 
recovery is not good. 

The appearance of complications in a case of 
pulmonary tuberculosis always renders the progno- 
sis worse to a degree corresponding to the impor- 
tance of the complications. 

Laryngeal tuberculosis, while it may simply in- 
dicate an extension of the tubercular process, adds 
so much distress to the case that it hastens the 
end. 

Hemoptysis, while it may not have much effect 
during the first stage, always becomes a serious 
complication during the second and third stages. 

Pneumonia, while it may be a rare complication 
of chronic phthisis, renders the immediate prognosis 
more grave; the same is true of bronchitis. 



278 PULMONARY TUBERCULOSIS. 

It is difficnlt to state the effects of a pleural 
effusion upon a case of pulmonary tuberculosis, but 
if purulent or hemorrhagic it is then unfavorable. 

Diarrhea, whether due to ulceration of the 
intestines or lardacious disease, always renders the 
prognosis worse. 

Albuminuria when dependent upon amyloid dis- 
ease or interstitial nephritis renders the prognosis 
grave. 

The prognosis is unfavorable in those cases 
where there is a strong hereditary tendency to the 
disease and when it develops early in life; in those 
who during childhood showed indications of scrofula 
and enlarged glands; in those with narrow chests 
who are dissipated; where there has been a great 
variation in the weight without apparent cause, and 
in those cases where edema of the feet and legs 
occur. 

The hereditary tendency should be considered 
in the prognosis, as this is worse in those cases 
where it is found upon both sides of the parental 
families; the younger member of the family will be 
apt to suffer more than the elder, as will also those 
bearing the greatest resemblance to the weaker 
parent. 

The condition under which the disease has de- 
veloped should be considered. If it has developed 
amid good surroundings the chances of recovery 
are not as good as in those cases where the sur- 
roundings have been bad and it is possible to 
greatly improve them. 

The condition of the patient should be consid- 
ered, as the early involvement of the apices of both 



i 



PULMONARY TUBERCULOSIS. 279 

lungs is always indicative of the rapid course of 
the disease. 

Treatment : — The treatment of chronic pulmo- 
nary tuberculosis must be general and not concen- 
-trated upon any one phase of the disease to the 
exclusion of others. For while the tubercle bacillus 
is the cause it is almost powerless in the presence 
of a system that is well fortified, one in which 
there is a high physiological condition present. The 
first consideration is the prevention as far as pos- 
sible of the spread of the disease, and as the 
sputum of tuberculous patients is one of the great 
sources of infection if not the greatest, it is 
evident that the first duty is the disinfection or 
destruction of the expectoration. To meet this 
requirement there is nothing as efficacious as a 
five per cent, solution of carbolic acid, into which 
the patient expectorates; a short exposure to this 
solution renders the bacillus harmless. Where it is 
possible the destruction of the sputum by fire in 
a furnace is a reliable method of disposing of it. 
Following the disinfection of the sputum it may be 
disposed of by being placed in a drain. Under no 
consideration should the sputum be allowed to dry 
and be swept up and thrown away with other dust, 
as it has then the greatest opportunity to infect 
others. 

The patient should, whether at home or in a 
hospital, use a sputum cup or a spittoon containing 
a disinfectant. If a handkerchief or piece of cloth 
is used for receiving the sputum it should either be 
burnt, or scalded before being sent to the laundry. 
The patient should not be allowed to spit about the 
streets, yard or house, or any place where the ex- 



28o PULMONARY TUBERCULOSIS. 

pectoration can dry and become a source of infec- 
tion. All of the patient's underclothing, as well as 
his bed clothing, should be scalded before being 
laundered. He should not be allowed to occupy 
a bed with any other person; the sleeping and liv- 
ing rooms should be cleaned with a damp cloth 
and the room thoroughly cleaned, painted, papered, 
etc., before being occupied by anyone else. If the 
patient sits at the same table with other members 
of the household attention should be given to his 
table utensils that they may not be mixed, the 
patient having his own. 

A child should not be nursed by a mother who 
is suffering from tuberculosis; a healthy wet nurse 
should be procured for such children and later in 
life attention should be devoted to their diet that it 
may at all times be easily assimilated, nutritious, 
and abundant. During the early years the diet 
should be principally milk or cream, eggs and 
meat juice. The child should be weighed at regu- 
lar intervals that it may be positively known there 
is a gradual increase in weight taking place. The 
milk used should be pure and free from tuberculous 
infection; milk is a common means of conveying 
the infection. It is advisable to boil the milk where 
there is any doubt regarding its purity. 

This class of patients do best in a dr}^ bracing 
country air. Their room should be large and well 
ventilated both night and day; they should spend 
much time in the open air, and adopt exercise that 
will expand the chest, and develop the aerating 
capacity of the lung; this should be a part of their 
early training. 

The clothing while light should be woolen and 



PULMONARY TUBERCULOSIS. 281 

sufficient to protect the body in every part, special 
care being taken to protect the feet and to prevent 
chilhng during sudden changes in the temperature. 

Baths: — During the first four or five years of 
life the baths should consist of warm or tepid water, 
while later it may be found that the tonic effect of 
a cold bath followed by thorough rubbing is of 
advantage to the patient. Sea bathing combined 
with sea air is often of great service to these 
patients, especially if glandular enlargement is 
present. 

The diseases of childhood should always receive 
close attention; those at least that are liable to be 
complicated with bronchitis or broncho-pneumonia. 
The condition of the naso-pharynx and throat should 
be closely examined for adenoids and enlarged ton- 
sils; these interfere with the normal respiration and 
expansion of the chest besides furnishing an avenue 
through which infection is made easy. The feeding 
should be forced; this is best accomplished by in- 
creasing the number of meals during the da3\ 

The diet of those advanced in years should 
alwa3's be generous, and while it should consist 
of mixed foods there should be a large proportion 
of fatty constituents. When it is found difficult to 
get the patient to take the necessary amount of fats, 
pure cod liver oil may be given; this will be found 
beneficial to these patients in the fall of the year, 
when it will fortify them against the winter. While 
this oil has no specific virtues it is a most valuable 
adjuvant, but should not be used in such large 
quantities that it becomes obnoxious to the patient. 
Two or three drachms two or three times a day 
will be as much as an ordinary patient will digest 



282 PULMONARY TUBERCULOSIS. 

at first, and in some cases it will be found neces- 
sary to commence with even a smaller dose. In 
cases of dyspepsia and where the taste of the oil 
continues to rise in the mouth it should be with- 
held. It is best to administer it shortly after the 
regular meal. In many cases it will be found nee- 
essar}^ to disguise the taste of the oil by the use of 
lemon juice, orange wine, or an emulsion with a 
preparation of malt. Glycerine has been recom- 
mended in doses of from three to four tablespoon- 
fuls, but it has not been used to the extent that the 
oil has. 

Alcoholic stimulants should not be recommended 
indiscriminately. Where the pyrexia is marked, 
the appetite poor, and a condition of general debil- 
ity is present, a small amount, about one drachm, 
in hot milk will be found of service. Brandy and 
whiskey are usually of the most service but they 
have no influence in bringing about sclerotic changes. 
In cases where there is a continual and obstinate 
anorexia the stomach tube will be found of service 
in feeding patients. 

The hygienic surroundings should be carefully 
noticed. The home should have if possible a south- 
ern exposure. It should be upon an elevation where 
the drainage is good and the soil porous. The 
sleeping rooms should be large, well ventilated and 
suitably warmed. When the patient is able he 
should take systematic exercise in walking, riding, 
and out-of-door games that do not demand too 
great exertion, as cycling, shooting, fishing, and 
golf, providing there is no pyrexia and the general 
condition is good. When the case is further ad- 
vanced he may be taken out during favorable 



PULMONARY TUBERCULOSIS. 283 

weather in a carriage or bath chair, or may sit 
out of doors under shelter. When the disease is 
still further advanced much benefit may be derived 
from conveying the patient to a sheltered spot 
either out of doors or upon a balcony where he 
can spend much of the day in the open air. 

Breathing: — It should be ascertained whether or 
not the patient knows how to breathe, as this is the 
most carelessly performed of all involuntary acts of 
the body. Many do not use half of their lung 
capacity, thus depriving the system of much oxygen 
and weighing it down with carbonic acid. To re- 
move this there is nothing that equals full deep 
breathing. The patient should be instructed to fill 
the chest as fully as possible with air and retain it 
while ten are counted then slowly expel it. This 
exercise should be continued five minutes, and re- 
peated several times each day. The period of hold- 
ing the air in the lungs should be increased each 
day. 

The breathing should be through the nose; the 
clothing as loose as possible that there be no re- 
striction to the chest wall. During breathing the 
patient should stand erect, the chin down, the head 
erect, the shoulders held back and down, and then 
rise upon the toes as he inhales; after holding the 
breath as has been already described for a gradu- 
ally-lengthening period that the air may act upon 
the blood, he again comes down upon the heels as 
the air is being expelled as completely as possible. 
This exercise should be continued at least each 
night and morning and oftener if possible. Not 
only should the patient be instructed how to breathe 
properly but carriage of the body should be im- 



284 PULMONARY TUBERCULOSIS. 

pressed upon the patient while exercising or attend- 
ing to his work. 

Rest: — In the majority of these cases the re- 
serve force is exhausted and rest is demanded. 
This must be adapted to the individual case; if it 
is found that the patient becomes easily fatigued, 
that exercise causes a decided rise of the tempera- 
ture, or if the temperature is continually above 100° 
F., confinement in bed is highly beneficial until such 
times as the temperature is below 100° F., and 
moving about does not cause a rise of the temper- 
ature or fatigue. To accomplish this may require 
from four to eight weeks or even longer. When 
the times arrives that the patient is allowed to get 
up it should only be for a few minutes at a time 
at first, that no exhaustion may result. These 
periods may be gradually lengthened. During this 
time he may be placed in the open air and sun- 
shine, care being taken that there be no undue ex- 
posure. 

Exercise should not be forced upon these 
patients too rapidly, for it is a fallacy to conclude 
that because exercise gives strength during health 
it will always do so during sickness. There must 
be a reserve force to expend in exercise, otherwise 
it is injurious. The appetite and digestion are 
usually improved by rest; digestion is poor during 
exhaustion. The equilibrium of the circulation is 
benefited as the number of cardiac contractions are 
lessened, and thus the saving in the strength. 
These patients should be protected from acts of 
imprudence to which they are prone on account of 
the hopeful state of their mind. ' 

Climate: — - The most inimical force to which 



PULMONARY TUBERCULOSIS. 285 

the tubercle bacilli can be subjected is fresh air. 
In considering the subject of a change of climate 
the condition of the patient should always be 
included for while the process is yet in the first 
stage, the greatest benefit is to be looked for; 
when consolidation and softening have taken place 
the patient should remain at home. The elements 
to be sought for in ^ a climate for consumptives are 
moderate and equable temperature, purity and dry- 
ness of the atmosphere, an excess of sunshine, and 
a medium altitude of from 2000 to 4500 feet. The 
patient with much destruction of lung tissue, defec- 
tive energy, and a weak heart should avoid high 
altitudes. But these will be found serviceable dur- 
ing the incipient stage, as they act as a powerful 
stimulant. Such climates are found in Colorado, 
Arizona and New Mexico in North America; in the 
Alps of Switzerland, in the Andes of South Amer- 
ica, the Himalaya Mountains, the Orange and 
Transvaal Provinces. 

For those who are continually debilitated, with 
a weak heart and rapid pulse, poor appetite, and a 
decided elevation of the evening temperature, a 
marine or inland climate that exerts more of a 
sedative influence will be found more serviceable, 
such as is found along the western coast of the 
Gulf of Mexico, through Southern California and 
Mexico. The warm climate and dry inland plains, 
as found in Texas and Australia are also service- 
able to this last group of patients. For those who 
are still more advanced, the ocean climate, espe- 
cially of the warm latitudes, is of more benefit. It 
should be of some duration, such as would be ob- 
tained from a trip across the Pacific and back on 
a sailing vessel. 



286 PULMOxNARY TUBERCULOSIS. 

Static electricity acts as a stimulant in many of 
these cases, quieting the nervous system, improving 
the circulation, giving sleep, and toning the whole 
body. The static current of lower power adminis- 
tered for two or three hours a day is of great value. 
Complete directions for its use may be found in any 
work on the subject of static electricity. 

The physician should devote his attention to the 
general management of the cases that close their 
career under his care. The temperature of the 
patient's room should be maintained at about 70° F., 
with the atmosphere sufficiently moist that a cough 
will not be provoked. If it is found that the 
changing of the clothing at night causes much 
annoyance, the underclothing may be worn for three 
or four days without changing, excepting those 
cases where there is a great amount of perspira- 
tion. 

When the fever is high the patient should be 
confined to bed and the body sponged with cold or 
tepid water to which a little vinegar or bicarbonate 
of soda has been added. The application of an ice 
bag over the diseased lung is often serviceable. 
The use of the antipyretic remedies are attended 
with such depressing after-effects that they are 
often of more injury than beneiit. 

The cough at times is very annoying. The 
patient should understand the object of the cough, 
that it is a necessity only when there are secre- 
tions to be expelled, that it is not necessary to 
cough for every slight irritation, and that many 
times it can be controlled by the w^ill. The earl}^ 
morning cough in these cases is a necessity and 
should be encouraged. A cup of hot milk to which 



PULMONARY TUBERCULOSIS. 287 

a teaspoonful of whisky has been added before the 
coughing commences is frequently of benefit. When 
there is material to be expectorated the lung should 
be filled with air and then emptied with one expul- 
sive effort that carries the secretions with it. In 
these cases where large cavities have formed, the 
patient should " cough down hill." This may be 
accomplished b}^ lyii^g across a bed upon the 
stomach, and bringing the head and shoulders over 
the edge so that by gravitation the secretions pour 
from the cavities. It may be necessary to turn 
from side to side while in this position in order to 
empty all the cavities. 

When the coughing produces a pain about the 
chest wall, adhesive straps or the application of a 
bandage that will immobilize the part is of service, 
and such remedies as bryonia, kali carbonicum and 
scilla should be considered. 

When the cough is provoked by the cold bed 
clothing, the latter should be warmed. In some 
cases coughing is induced by the patient lying upon 
the side of the diseased lung. In those cases 
where an iiritating cough is present at night fol- 
lowing retirement, a small amount of stimulant, as 
wine or whisky, at times controls it; sometimes 
smelling of spirits of camphor or a few drops of 
chloroform often gives relief. 

A diarrhea becomes very annoying when ulcer- 
ation of the intestines has taken place. In some of 
these cases a thorough washing out of the bowel 
with a large quantity of warm water every day or 
two is serviceable. A hot linseed meal poultice or 
a mustard plaster prepared by boiling mustard in 
castor oil and applied to the abdomen is beneficial; 



288 PULMONARY TUBERCULOSIS. 

the latter may be left in position twelve hours. 
At times when the contents of the bowels are very 
offensive a thorou^^h cleansing with castor oil is 
beneficial, and opens the way for other measures. 
Should there still remain some disturbance such 
remedies as hydrastis, bismuth, arsenicum, sulphur, 
mercurius, china or argentum nitricum should be 
studied. 

Vomiting after taking food is often very annoy- 
ing. This can usually be partially avoided by 
giving the patient a small quantity of some warm 
drink, as hot milk or a cupful of beef tea about a 
half hour before the regular meal; this will cause a 
free expectoration of the secretions which as a result 
does not take place later, when the regular meal is 
taken. 

Night sweats are common and not always easy 
to control. If possible it should be determined 
whether the}^ are the termination of the crisis of 
the hectic fever, the result of exhaustion, or a con- 
dition of the skin common to this disease. They 
appear as the fever declines early in the morning. 
In these cases the body should be sponged with 
cold water at night and a glass of hot milk admin- 
istered before the sweating appears in the morning. 
When sweating has taken place all of the clothing 
and bedding that has been dampened should be 
removed and replaced by dry ones, the skin rubbed 
dry, and some hot milk or other liquid nourishment 
given, keeping the patient at rest and in the fresh 
air. 

In some of these cases calcarea hypophosphite 
will be found to be indicated. Aromatic sul- 
phuric acid in doses of from 15 to 20 minims 



PULMONARY TUBERCULOSIS. 289 

given in cinnamon water, upon retiring is sufficient 
in mild- cases; in others atropine, given subcutane- 
ously in doses ranging from 1-200 to 1-60 of a 
grain, is of service, but in many it produces a dry- 
ness of the throat, unpleasant taste, a disturbance 
of the vision, and possibly a gastro-intestinal irrita- 
tion. Picrotoxine in doses of from 1-180 to i-6o of 
a grain has also been employed. Agaricine ix, one 
tablet on retiring is frequently of benefit. It may 
be necessary to repeat, or to give a dose two or 
three times during the day. Camphoric acid in 
doses of from 15 to 60 grains in water has been 
much used. It is best given upon an empty sto- 
mach. Such remedies as phosphoric acid, arseni- 
cum, cinchona, and silicea are often indicated. 

When hemorrhage appears the patient should be 
kept quiet upon his back with ice bags over the 
diseased lung, and such other methods adopted as 
are mentioned in the chapter on hemoptysis. Pain 
about the chest wall is usually relieved by strap- 
ping, bandaging the part, or applying a mustard 
paste. 

When the patient is confined to his bed, bed 
sores must be guarded against by rubbing the back 
with alcohol and protecting reddened areas by cot- 
ton or rubber rings. 

When the cough and expectoration is excessive, 
the latter being offensive, or where there is much 
dust, a respirator may be worn with a few drops 
of oil of eucalyptus upon the cotton. 

The chest capacity may be increased by breath- 
ing a compressed or rarefied air by the aid of the 
pneumatic cabinet. 

19 



290 PULMONARY TUBERCULOSIS. 

The sanatorium treatment of consumption is to 
a large extent based upon the truth that the great 
virtue of all resorts is the open-air life. While it 
is true that certain climates are more favorable than 
others for a recovery from tuberculosis, yet it is not 
possible for all to reach these points; and it has 
been found that near to the home of all it is pos- 
sible to establish and conduct sanatoriums in such 
a way as to eliminate much of the objectionable 
and combine most of the desirable features of the 
open air treatment. When a patient has improved 
by such a method of treatment in a mild climate 
he will resent enduring the same open-air treat- 
ment upon returning home where the climate is 
more severe. But if the treatment has been in a 
climate such as he has at home the change will 
not be so noticeable. 

In a general way the results of the treatment 
are shown by an increase of weight; many cases 
being cured or improved; while the general health 
is always improved. 

Books can be procured upon the subject of 
sanatorium treatment; and it must suffice here to 
say that the conquering idea is an abundance of 
pure air outdoors all the time night and day, 
together with plenty of good food, rest, and sleep, 
without fatigue or worry. 

Tuberculin: — The efficacy of this remedy has 
been so frequently demonstrated that it demands 
a 'place among therapeutic agents. There is a 
frontal headache, with heaviness of the head and 
buzzing in the ears. The tongue is brown and 
dry, the breath is fetid, while the gums are ulcer- 
ated and bleed easily. There is dryness of the 



PULMONARY TUBERCULOSIS. 29I 

throat with general inflammation of the respiratory 
tract; pain in the stomach with hyperemia of the 
spleen and liver: diarrhea with nausea and vomit- 
ing. There is pain in the renal region, with 
hematuria and an excess of urates. The larynx 
and glottis are inflamed and edematous; the cough 
may be dry or loose. The expectoration is easy 
and accompanied by a feeling of heat in the chest. 
There are post mortem evidences of lobular pneu- 
monia. The respirations are increased in fre- 
quency, while dyspnea and pleurisy are present. 
The lymph glands are enlarged and the serous 
surfaces are affected. There are anemia, insomnia 
and fever. 

Phosphorus: — This remedy is frequently indi- 
cated in cases of incipient as well as in the more ad- 
vanced cases of phthisis; the patient is tall, slender, 
with fair skin, sanguine temperament, and of sen- 
sitive disposition. There is a sensation of great 
weakness and emptiness in the stomach and abdo- 
men, aggravating all of the other symptoms. The 
patient is thirsty and drinks large quantities of 
water, but it is all vomited as soon as it becomes 
warm in the stomach. The bowels may be con- 
stipated, the stools are slim, hard, dry, and evac- 
uated with difficulty, or there is a painless diar- 
rhea when large quantities of fluid pour from the 
rectum as water from a hydrant. The cough is 
dry and hacking, with burning and tickling in the 
air passages and stitches in the chest. There are 
frequent hemorrhages from the lungs accompanied 
by heat between the shoulders. The patient is 
emaciated, sensitive to sudden changes of the 
weather and takes cold easily. 



292 PULMONARY TUBERCULOSIS. 

Sulphur: — This remedy is to be studied in the 
cases of those with psoric constitution of a lym- 
phatic temperament who are subject to venous 
plethora and hemorrhoids. There is a sensation 
of heat on the top of the head, while the palms 
of the hands and soles of the feet are so hot that 
the latter must be put out of bed to keep them 
cool. There is a general sensation of heat com- 
plained of all over the body, with an acid, excori- 
ating, morning diarrhea that causes the patient to 
go to stool as soon as the desire is felt. About 
II a. m. the patient becomes weak and faint and 
must have something to eat — cannot wait for din- 
ner. When the bowels are constipated the stools 
are dark, hard, dry, and are expelled only by 
great force, and are accompanied with bleeding 
and hemorrhoids. The patient feels suffocated and 
wants the doors and windows open. There are 
frequent flashes of heat, with faintness, followed 
by a general perspiration and debility. There is 
a marked sensitiveness of the skin, so that every 
every trifling change in the temperature is felt. 
There is much rattling of mucus in the chest, the 
patient gets worse as the cough becomes loosen 
There is frequently a history of some vesicular 
skin disease in the case curable with this remedy. 

Calcarea carbonica: — This is an important rem- 
edy in scrofulous and tubercular persons of the 
lymphatic temperament. They have large heads, 
are pale, with a flabby skin, and have a white, 
chalky look. In a child the fontanelles are open 
and there is a profuse perspiration about the head 
and chest. The patient is greatly exhausted, 
especially by going up stairs. The feet are cold 



PULMONARY TUBERCULOSIS. 293 

and feel as though the stockings were damp. 
There is great emaciation, with a constant ten- 
dency to take cold, especially from a cold east 
wind which seems to go through him. There is 
hectic fever with a tendency to perspire about the 
head and chest. There is a sour condition of the 
stomach with sour vomiting, a chronic watery 
diarrhea and the food is not digested. The 
menses are too profuse and frequent in women. 
The whole chest is painful to the touch and the 
cough is accompanied by a profuse expectoration 
which early becomes purulent. 

Sanguinaria canadensis: — In cases of catarrhal 
phthisis where the cough has passed into the 
second stage and the lungs are filled with mucus 
and the cough sounds loose but the mucus is 
raised with difficulty this remedy should be 
studied. The cough is severe and is attended 
with flushing of the face and hectic spots upon 
the cheeks. There is emptiness of the stomach, 
which is worse after eating, and a constant tick- 
ling at the entrance to the larynx and down 
behind the sternum. The chest is sore and pain- 
ful to the touch. There is burning of the palms 
of the hands and soles of the feet, or the hands 
are cold and the nails are blue. 

Silicea: — This is a great remedy during the 
suppurative process when there is a loose, racking, 
suffocating cough, with a copious expectoration of 
thick, yellow or greenish pus, accompanied by a 
hectic fever, great emaciation, weakness, and de- 
bilitating night sweats. The patient is chilly and 
cannot keep warm even while walking. There is 
a disposition to take cold from every draft, and 



294 PULMONARY TURERCUI.OSIS. 

the head and chest are constantly wet with per- 
spiration. The bowels are constipated, the stools 
receding after having been partially expelled. The 
greatest benefit is derived from this remedy when 
prescribed in the higher triturations. 

Lycopodium: — This is an important remedy in 
phthisis. The cough is loose and rattling, the 
expectoration is difficult, the sputum remains in 
the lungs and is thick, yellow, or greenish; there 
is also great difficulty in breathing while coughing. 
There is a fan-like motion of the alae nasi. The 
urine contains large quantities of uric acid. There 
is pain in the small of the back which is relieved 
by urinating. He has a constant feeling of satiety, 
the least morsel of food fills him up with a feel- 
ing as though a pot of yeast were working in the 
abdomen, and the bowels are obstinately consti- 
pated. The patient is inclined to take cold with 
every change of the weather and suffers frequently 
from a cold clammy night sweat about the head 
and chest. In prescribing this remedy it should 
not be below the 30X; its action on the digestive 
organs, liver, and kidneys should be remembered. 

Acidum phosphoricum: — This remedy is fre- 
quently of service during the first stages of 
phthisis where there is great debility from loss 
of animal fluids, as from sexual excesses or pro- 
longed immoral emotions. The patient is indifferent 
to everybody and everything; there is cerebral 
weakness from brain fag so that he can hardly be 
persuaded to speak. There is a painless, watery 
diarrhea with much rumbling in the abdomen 
from accumulations of flatus. The stools are 
undigested. 



PULMONARY TUBERCULOSIS. 295 

Pulsatilla: — In cases of phthisis where the 
bronchial mucous membrane is greatly involved 
there is a very loose cough accompanied with a 
copious expectoration of mucus of a white, yel- 
lowish, or greenish color, lumpy in character and 
salty to the taste. The patient is affectionate, with 
blue eyes, yielding disposition, and easily excited 
to tears. The symptoms are made worse by being 
in a close, warm room, patient desires to be in 
the fresh cool air, yet she complains of being cold 
at all times. The cough is loose, rattling, and 
racking, making the stomach sore and causing 
emissions of urine with each paroxysm of cpugh- 
ing. There is a bad taste in the mouth in the 
morning, the digestion is poor, the tongue coated 
white or yellow. There is a sour stomach from 
the least digression in diet, especially from the 
effects of rich fat foods. 

Kali carbonicum: — The patient is emaciated and 
debilitated and has a strong tendency to tubercu- 
losis. There is dryness of the scalp, with falling 
of the hair, and a predisposition to take cold from 
every change of the weather. There is a cough 
that appears as .the result of cold damp weather; 
it is dry, paroxysmal, and attended with vomiting 
or gagging. It commences about 3 a. m., when 
viscid mucus or pus is loosened which must be 
swallowed or expectorated. There are stitching, 
darting pains, which are worse during rest and 
when lying on the affected side. 

Kali iodatum:^The action of this remedy is 
most pronounced in scrofulous, syphilitic patients, 
who have taken large quantities of mercury. The 
lymphatic glands are enlarged. The mucous mem- 



296 PULMONARY TUBERCULOSIS. 

branes are in a state of chronic inflammation, 
ulcerated so that there is a fetid odor from the 
nose and mouth. There is irritation of the bron- 
chial tubes, with a hollow, dry cough, day and 
night, which is worse toward evening, and may be 
attended with a viscid, ropy expectoration. There 
is heat in the chest, with burning and tickling of 
the larynx. At times there is a severe coryza, 
the nose being red and swollen, with a profuse 
watery nasal discharge. In the chronic cases there 
are large quantities of secretions in the bronchial 
tubes which are green in appearance. The pa- 
tients are worse in cold, damp weather, and from 
rest, and are relieved by motion and by being 
in warm, dry air. 

Arsenicum album: — This is of service in those 
of a lymphatic nervous temperament, who are 
greatly debilitated and emaciated, and where there 
is rapid emaciation with great prostration and sink- 
ing of the vital forces. They are restless, with 
anguish of mind and fear of death. The face is 
pale and waxy. There is craving for acids, with 
great thirst for cold water, drinking often, but lit- 
tle at a time, which disagrees. There is a watery 
diarrhea, the stools being very offensive. There 
are burning pains, the parts burn like fire. The 
cough is usually dry and there is a sensation as 
though sulphur fumes had been inhaled. There is 
nausea and vomiting, with general anasarca and 
cold night sweats. 

lodium: — This is a great constitutional remedy 
for the low cachectic state, where there are en- 
larged glands with a sense of great weakness and 
loss of breath upon going upstairs. The patient 



PULMONARY TUBERCULOSIS. 297 

is usually dark and has black hair and eyes. 
There is ravenous hunger, the patient eats plenty 
yet is losing flesh all the time. All the symptoms 
are relived while eating. The cough is usually 
dry, attended with hoarseness and copious night 
sweats. All the symptoms are worse from warm 
air and better from cold. 

Antimonium iodatum: — This remedy will be 
found serviceable when with the above symptoms 
there is a profuse purulent expectoration. 

Acidum sulphuricum: — In the last stages of 
the disease, with aphthous sore mouth and ulcera- 
tion of the mucous membrane which is exceed- 
ingly painful this is the first remedy to study. 
There is great debility with a sensation of tremor 
all over the body without trembling. The ex- 
haustion is pronounced, with profuse night sweats. 
The diarrhea is attended with great prostration 
and accompanied by hemorrhages of dark venous 
blood from all the orifices of the body. The 
second or third decimal of the pure drug will be 
found to act well. In the last stages it may be 
applied to the mouth by means of a spray or by 
being mixed with glycerine and applied with a 
brush. 

Baptisia tinctoria: — This remedy should be 
studied when the secretions are fetid and the 
breath foul; this is most marked during the last 
stages of the disease, when the glands of the 
bowels are ulcerated and there is diarrhea, — the 
stool and urine being very offensive. The tongue 
is coated brown, is dry, and the breath is offensive. 
There is tightness of the chest so that the patient 
breathes with difficulty. The cough is loose, the 



298 PULMONARY TUBERCULOSIS. 

expectoration muco-purulent and very fetid. There 
is a chill at 10 a. m. and 3 p. m. The tempera- 
ture is high, with a sinking sensation at the stom- 
ach. The parts rested on feel sore and bruised. 
He can swallow nothing but liquids. 

Stannum: — Think of this remedy when the 
bronchial tubes are inflamed and dilated, and there 
is a great amount of mucus secreted which is 
green, yellow, or muco-purulent in character. 
The cough is loose, rattling, and accompanied by 
great weakness of the chest, and the least exer- 
tion renders the patient breathless. He cannot 
answer questions as it renders him breathless. He 
feels so weak he can sit down only with great 
difficulty, must usually drop down suddenly. The 
weakness renders it almosf impossible for him to 
come down stairs. The pain begins lightly but 
increases gradually to a high degree — then de- 
creases as slowly. There is a rough throat with 
hoarseness and exhausting night sweats. Stannum 
iodide at times will give better service. 

Rumex crispus: — The action of this remedy is 
most marked upon the mucous membrane of the 
larynx and trachea. There is a dry, hard, teasing 
cough that is made worse by inspiring cool air, by 
pressure about the larynx, and when talking. He 
cannot bear the cold air so covers up the head to 
exclude it. There is complete aphonia and sense 
of excoriation behind the sternum. 

Acidum nitricum: — This remedy is to be studied 
in cases where the constitution is broken down by 
syphilis or mercury. The patient is very weak, 
perspiring profusely at night, the perspiration smell- 
ing like horse urine. There is a feeling as if sharp 



PULMONARY TUBERCULOSIS. 299 

Sticks were being- stuck into the affected parts. 
Frequently there are mucus patches and ulcers of 
the mouth and throat which may be degenerating, 
and which render the breath fetid. There is diar- 
rhea with great pain in the anus, as though fis- 
sures were present. The stool may be mixed with 
blood. The urine smells like horse urine and is 
very offensive. All of the ^symptoms are worse at 
night, especially after midnight. 

Nux vomica: — This remedy is of benefit when 
the stomach symptoms are prominent. There is a 
sour or bitter taste in the mouth, with morning" 
headache, attended with retching, vomiting, and 
gastralgia. The bowels are constipated and there 
is ineffectual urging to stool. In some of these 
cases strychnia 3X will be found to act promptly. 

Under acute pulmonary tuberculosis the indi- 
cations for the following remedies are to be con- 
sidered: Ferrum phosphoricum, the hypophosphite 
of lime, hypophosphite of soda, chininum arseni- 
cosum, arsenicum album, arsenicum iodide, bap- 
tisia tinctoria, iodoform, and guaiacol. The 
reader is referred to the chapter on chronic bron- 
chitis for other leading remedies. Inhalations are 
of service from a mental standpoint and by de- 
manding as they do deep breathing, but have no 
direct influence over the bacilli; eucalyptus, creo- 
sote, terebene, guaiacol and formaldehyde are of 
service. They should not be used too strong. 



CHAPTER XXIX. 
ACUTE PULMONARY TUBERCULOSIS. 



Synonyms : — Acute phthisis; acute consumption. 

Varieties: — Lobar pneumonia; broncho-pneu- 
monia, acute mihary tuberculosis. 

Lobar pneumonia. In this form nearly all of 
one lobe becomes converted into a solid gelatinous 
or caseous substance. It is most frequently the 
upper lobe of the lung that is first involved, 
while the whole lung may be affected later. The 
consolidation has scattered through it indications 
of foci of older dates, showing that the diffused 
pneumonic process is secondary to a more local- 
ized tuberculosis. At times the first indication is 
a chill that may follow an exposure. The temper- 
ature rises suddenly and there are present all 
symptoms of a well marked case of croupous pneu- 
monia," with even the bloody expectoration and 
rusty sputum. 

In other cases the onset is not so abrupt; 
malaise is complained of, with aching in the back 
and limbs, a slight cough and expectoration before 
the pyrexia, and other pneumonic symptoms. The 
stage of consolidation appears early and the pro- 
cess spreads with great rapidity from lobe to lobe, 
so that the better part of the whole lung is early 
involved. The fever is high and continuous, the 
pulse is rapid, 120 to 140 to the minute. As the 
consolidation advances and involves more of the 



ACUTE PULMONARY TUBERCULOSIS. 3OI 

lung- the respirations become accelerated, but 
cyanosis and dyspnea are not marked. 

The physical examination reveals consolidation, 
dullness, tubular breathing, crepitant or subcrepi- 
tant rales, and usually bronchophony. In some 
cases the breath sounds are weakened, yet tubular 
breathing may not appear for some time; as the 
pleura is involved pleuritic friction sounds appear. 
The whole aspect of the disease is that of pneu- 
monia for which it is frequently mistaken. But 
about the ninth day when the crisis should appear 
the fever becomes irregular but still persists. 
There may be a slight abatement of the symptoms 
at this time for a few days, but soon the patient 
relapses into the former condition. The fever now 
assumes a remittent character, the evening tempera- 
ture becomes one or two degrees above the morn- 
ing (103° F. to 104° F.), while later the temperature 
falls and the fever assumes the hectic type. The 
patient loses flesh rapidly, becomes prostrated, and 
may develop a typhoid condition with a dry 
tongue, subsultus, a mild delirium, and signs of 
pulmonary cavities appear. The sputum is now 
muco-purulent, contains tubercle bacilli and elastic 
tissue. Often the end comes within two weeks, 
or life may be prolonged for five or six weeks, 
while occasionally the process assumes a chronic 
type and the end comes at a still later period. 

Diagnosis: — During the first ten days it is 
frequently difficult or impossible to make a posi- 
tive diagnosis. The fever in this form of the 
pneumonic process is less constant, being marked 
by remission; the ratio between the pulse and the 
respirations does not show as great a derangement 



302 ACUTE PULMONARY TUBERCULOSIS. 

as it does in acute pneumonia, for while the pulse 
rate may reach 130 to 140 the respirations are not 
more than 30 to 40 to the minute. Those cases 
of croupous pneumonia in which resolution is de- 
layed may be mistaken for tuberculosis, but in the 
latter there is a great degree of prostration and pro- 
gressive wasting and a fluctuation of the tempera- 
ture that is not met with in the former. A posi- 
tive diagnosis can only be made by the detection 
of the formation of cavities and the presence in 
the sputum of the tubercle bacilli and elastic tis- 
sue. The complications, while similar to those 
found with the more chronic forms of pulmonary 
tuberculosis, are not so frequent, owing to the 
greater rapidity of the disease. 

Broncho-pneumonic form: — While this form is 
not as frequently met with as the one just de- 
scribed it constitutes what is known as galloping 
consumption, or Phthisis Florida. There are dis- 
seminated through the lungs tuberculous foci of 
different sizes and a greyish or yellowish white 
color which are soft and cheesy. These soften 
and break down early, giving rise to excavations 
and suppurating cavities with soft ragged walls. 
They are scattered through both lungs and are 
usually most numerous and largest in the apices 
of the upper lobes, which point may be the loca- 
tion of an old fibrosis. The lung tissue between 
the nodules often shows infiltration, and in time 
there may be a fusion of the various foci leading 
to the lobar rather than a lobular involvement. 
The bronchial tubes become filled with an abun- 
dant purulent secretion early in the history of the 
case, this being the explanation of the involvement 



ACUTE PULMONARY TUBERCULOSIS. 303 

of the larynx and air passages, with tubercular 
ulceration in many of these cases. Pleurisy in 
some form is present. 

Symptoms: — The mode of the onset of this 
form varies. In some cases it is gradual; a cough 
is first observed; after a few weeks a fever appears 
with malaise and other constitutional symptoms; 
occasionally hemoptysis is the first thing com- 
plained of, while in other cases it may be the de- 
velopment of certain gastric disturbances with loss 
of appetite, furred tongue, and vomiting; but it is 
not until a careful physical examination of the 
chest is made that the real trouble is recognized. 
This form has frequently been observed following 
influenza where there is marked emaciation and 
loss of strength. Hemoptysis when present is not 
profuse. The sputum at first is muco-purulent, 
but gradually becomes more purulent and may be 
of a greenish, or in some cases of a reddish brick 
dust color, and before the disease has progressed 
very far the sputum will show tubercle bacilli and 
elastic tissue. The fever fluctuates, having a 
morning remission of one or two degrees. The 
temperature frequently reaches 104° F., and as the 
disease progresses becomes more hectic; an aphthous 
stomatitis is apt to appear, with anorexia, vomit- 
ing, a dry red tongue, diarrhea, and frequently a 
typhoid condition develops. In severe cases the 
end may come in from three to four weeks, but 
more frequently it is in from three to four months, 
and again it may be from eight to ten months. 

Physical examination: — During the early 
stages the symptoms are similar to those seen in 
a case of bronchitis with consolidation, and later 



304 ACUTE PULMONARY TUBERCULOSIS. 

signs of excavations. These signs may appear at 
the base of the lungs rather than at the apex, and 
in cases where death is early no signs of caver- 
nous formation are to be found, as there has not 
been the necessary time for their formation, and 
the distended lung between the different foci hin- 
ders the observance of these small foci at first. 

Diagnosis'. — Early in the case this rests upon 
the recognition of a broncho -pneumonia with a 
high degree of prostration and loss of flesh, while 
the detection of elastic tissue and tubercle bacilli 
in the sputum is proof positive. In the cases of 
young children the matter of diagnosis is more 
difficult as there is no sputum and death takes 
place before cavities form. 

ACUTE MILIARY TUBERCULOSIS: — This is spokcn 
of as the typhoid form of acute tuberculosis. It 
differs from chronic tuberculosis of the lung only 
in the more acute course it pursues and in the 
widespread systemic involvement; so that as one 
organ appears to be more involved than another; it 
is spoken of as pulmonary, abdominal, or cerebral. 
In the pulmonary form the disease may pursue an 
acute or sub-acute course. In many of these cases 
a period of ill health has preceded the appearance 
of the disease. The first symptoms noticed are 
cough, expectoration, dyspnea, and pleuritic pains. 
In many cases the dyspnea early becomes the most 
prominent symptom and is often attended with 
cyanosis. The fever becomes high, 103° to 104° F.; 
the morning remissions are not as pronounced as 
are those of broncho-pneumonic form, yet cases are 
met with that i"un their course without any marked 
or definite elevation of the temperature. The pulse 



ACUTE PULMONARY TUBERCULOSIS. 305 

becomes rapid and weak, the face and extremities 
are of a dusky color, and emaciation is rapid. 
There is more or less stupor present with delirium. 
As a typhoid condition develops the prostration 
becomes more pronounced, a profuse perspiration 
appears, and a diarrhea and tympanitic condition of 
the abdomen are often observed. 

Physical Examination: — Early in the history of 
the case the physical signs are such as would indi- 
cate a general bronchitis; the anterior portion of 
the lungs is hyper-resonant, while later pleuritic 
friction sounds are heard and small areas of dull- 
ness are to be noted, indicating a secondary bron- 
cho-pneumonia. A lobar pneumonia may develop. 
The patient loses flesh and strength rapidly, the 
dyspnea, cyanosis and cough become gradually 
worse and the sputum becomes muco-purulent. 
Tubercle bacilli are not found early in the sputum. 

The diagnosis is often difficult. When the 
bronchitis is associated with marked dyspnea, cyan- 
osis, and rapid emaciation, the diagnosis is then 
easier. 

Prognosis : — This is grave in all forms of acute 
pulmonary tuberculosis; while it is claimed that re- 
coveries have taken place they have been in cases 
of very limited infiltration. It is not as grave in 
the lobular as in the lobar form, and while there 
may be periods of apparent improvement, yet death 
results sooner or later as a result of the disease. 

Treatment: — This should embody many of the 
directions laid down in the section on chronic 
tuberculosis. The patient should have absolute rest ' 
in bed, the air of the room being as pure as possi- 
ble; his strength must be maintained as in this lies 



306 ACUTE PULMONARY TUBERCULOSIS. 

his hope. An abundance of Hquid food should be 
given every two hours; this should only be limited 
by the power of the digestive organs to utilize it; 
care should be exercised that nothing is done to 
interfere with the power of the organs. No drug 
should be employed that has for its end the lower- 
ing of the temperature alone, as it will have no 
influence upon the pathological process and will 
have a depressing effect upon the heart. Sponging 
of the body with water at a temperature of 85° F. 
or 88° F. in which is dissolved a little bicarbonate 
of soda or in which a little vinegar has been placed 
is often gratefully received by the patient. This 
should be done during the afternoon when the fever 
is highest. 

Ferrum phosphoricum: — This remedy is indicated 
during the early stages before any septic symptoms 
have developed. There is congestion of the lung 
with debility, the breathing is short, oppressed and 
hurried. The fever is high, the respiration short, 
and there is apt to be hemoptysis or nosebleed, 
with flushed face, headache and great prostration; 
phthisis florida. 

Calcium hypophosphorosa ( hypophosphite ) : — 
The face is pale and emaciated. There are night 
sweats with lassitude, prostration, headache, fever, 
loss of appetite, diarrhea, and hemoptysis. There 
is cough with severe pains in the chest. The ex- 
tremities are habitually cold. This remedy is of 
great service in children and in pregnant women. 

Natrum hypophosphorosum ( hypophosphite ) : — 
This is frequently of service in the earl}^ histor}' of 
the case. The patient is frequently in an anemic 
condition; there is marasmus and wasting of the 



ACUTE PULMONARY TUBERCULOSIS. 307 

muscular system; a chronic bronchitis or pneumonia 
is present, with myalgic pains; there are indications 
that the hings will break down. 

Chininum arsenicosum: — This remedy is of ser- 
vice in these cases when there is great prostration 
and exhaustion of the vital forces, with decomposi- 
tion of the blood and marked septic symptoms; the 
symptoms have a marked regularity that would in- 
dicate malaria. 

Arsenicum album: — This is indicated b}' great 
restlessness, profound exhaustion, rapid emaciation 
and constant thirst for small quantities of cold 
water which is not retained. The case has ad- 
vanced and septic symptoms are appearing. 

Arsenicum iodatum: — This remedy may be indi- 
cated when the symptoms are more of the sub- 
acute type. There is great anxiety with rapid loss 
of flesh and tightness of the chest; the discharges 
are very irritating. The fever is high, there is 
cough with dyspnea, prostration and diarrhea. The 
expectoration is muco-purulent. 

Baptisia tinctoria : — This remedy is indicated 
when the septic symptoms have become prominent 
and are of a typhoid type. 

Iodoform (3X): — This remedy has been used 
with a degree of success in many of these cases. 
There is pain in the apex of the right lung, with a 
ieeling as from a heavy cold, as though a weight 
rested on the chest preventing free expansion. 

Guaiacol: — This remedy is of service in cases 
•during the early stages, when 5 to 10 drops of the 
IX will be found to act better in some cases than 
the regular dose of from 5 to 10 minims. 



308 FIBROID TUBERCULOSIS. 

HBROID TUBERCULOSIS. 

Definition: — This is a slow inflammatory tuber- 
cular process, characterized by a hyperplasia of the 
connective tissue of the lungs and pleura, which 
constricts the lumen of the bronchial tubes, and 
vessels of the lungs. 

Etiology: — The victims of this form of tuber- 
culosis are frequently well developed, and possess a 
high degree of resistance. Men suffer from it more 
frequently than women, while it does not develop 
until the later periods of life. There may be no 
family tendency to the disease, but it is observed 
more frequently in those who inhale large quan- 
tities of dust. 

Pathology :— The primary seat of this form is a 
caseous center located in the finer bronchi of the 
apex of the lung, and consists of tubercles which 
are typical, but which instead of undergoing caseous 
softening become transformed into firm, deeply pig- 
mented, fibrous bodies; which have a shot-like feel- 
ing in the pulmonary tissue. There is a fibrous 
thickening of the interlobular connective tissue, which 
in time interferes with the pulmonary vessels and 
bronchi, and leads to emphysema and constriction 
of the bronchi. In some cases small caseous masses 
and calcareous bodies may be found in the affected 
area as well as in the small, smooth walled cavities. 
A few bacilli ma}^ be found in the recently involved 
areas, but they are not present in the older fibrous 
lesions. 

Symptoms: — The onset is insidious; a slight 
cough, with loss of strength and weight and slight 
fever may be present. As the fibrous process in- 



FIBROID TUBERCULOSIS. 3O9 

volves more lung tissue there is an increase of the 
dyspnea, while the emphysema is more pronounced, 
and there are recurrent attacks of catarrhal bron- 
chitis and bronchial asthma. Cases are met with in 
which there are no catarrhal symptoms. Hemop- 
tysis is common during the early stages, when it 
may be profuse and occur frequently. The rise in 
the temperature is always moderate; the fever may 
be absent even during the advance of the disease, 
while the morning temperature is often below 
normal. The cough may be severe in cases where 
there is emphysema and catarrhal bronchitis, but in 
the majority of cases it is not severe. It rarely 
produces vomiting. There is but httle expectora- 
tion. It seldom contains the tubercle bacilli. There 
are no night sweats, diarrhea, or involvement of 
the larynx; the patient may be well nourished. As 
the changes become more extensive, emph37sema of 
the lungs and epigastric pulsation appear. 

Physical signs: — Inspection. The patient may 
appear well nourished. There is a slight flattening 
and lack of expansion over apex of one lung. The 
shoulder of the affected side is usually depressed, 
and dyspnea is present. The heart may show dis- 
placement toward the diseased lung. 

Palpation:-^ If there is much fever the pulse is 
quickened, otherwise it is not. The vocal fremitus 
is exaggerated over the affected area except in 
those cases where the pleura is greatly thickened 
or the bronchi contracted. 

Percussion: — This reveals dullness over the af- 
fected area with hyper-resonance over the healthy 
side. 

Auscultation: — This shows the vesicular murmur 



3IO FIBROID TUBERCULOSIS. 

to be absent and bronchial breathing to be present 
on the affected side, with exaggerated or normal 
breathing on the sound side and with fine rales over 
the affected area. These may only be audible upon 
coughing. 

Diagnosis: — On account of the emphysema and 
bronchitis this is not always easy. Careful atten- 
tion should be devoted to the apices of the lungs 
for signs of consolidation and to the sputum for 
bacilli. 

Prognosis: — This type of tuberculosis runs a 
very slow course, and under favorable conditions, 
when the changes are not extensive, it may be 
arrested, and yet there is ever a tendency for it to 
light up and the patient to die of some form of 
pulmonary disease. 

Treatment : — This does not differ from that of 
ulcerative phthisis. 



CHAPTER XXX. 
PLEURODYNIA, 



Synony?n : — False pleurisy. 

Definition: — This is rheumatic myalgia of the 
chest wall. 

Etiology: — It is seldom met with before the 
thirtieth year of age, but may occur in young 
people of distinctly rheumatic tendencies. It is most 
frequently the result of exposure to draughts and 
cold, coming out of over-heated rooms, especially 
in those who are subject to gout and rheumatic 
affections. 

Pathology : — As this term is frequently employed 
in speaking of different conditions, as aponeurotic 
rheumatism, myalgia, and intercostal neuralgia, it is 
evident that these conditions should be studied. 

Symptoms: — These appear suddenly, the pain is 
severe, tingling or burning in character and is much 
aggravated by respiratory movements, especially 
deep inspiration. He has a desire to hold the side, 
and shrinks from coughing. The pain is often 
catching in character and aggravated from deep 
pressure upon the part, although a broad pressure 
that will limit the movements often brings relief. 
While either side may be affected the left side is 
more frequently involved than the right. The pain 
may change its position. 

Physical signs: — Inspection. This shows the 
respirations to be shallow and more or less rapid, 
and the movements of the body to be restricted. 



312 PLEURODYNIA. 



Palpation: — There is tenderness upon pressure 
over a diffused area. 

Percussion: — There is no dullness. 

Auscultation: — There is a restricted normal 
vesicular respiration. 

Diagnosis: — This is made by exclusion and 
the presence of a more or less diffused tenderness, 
with no fever. 

• It should be distinguished from intercostal neu- 
ralgia, which is indicated by localized points of 
tenderness known as the points of "Vallei;" there 
is one behind near the dorsal vertebrae, one later- 
ally and one near the sternum. 

Pleurisy and pericarditis should also be distin- 
guished from pleurodynia, which is usually readily 
done by the presence of fever and friction sounds 
in the former, and the prominence of superficial 
pain in the latter. 

Prognosis : — It does not endanger the life but is 
very annoying. 

Treatment : — Many of these patients are anemic, 
poorly nourished, and must be built up. The pain- 
ful point should be covered with oiled silk or other 
material that will keep the affected part perspiring. 
Strapping of the side to immobilize it is of service, 
as well as applications of the faradic current which 
usually relieve after a few applications. If some- 
thing to be rubbed on is demanded, a compound 
chloroform liniment will be found beneficial. 

The remedies are those indicated by the consti- 
tutional symptoms. 

Ranunculus bulbosus: — This is a most valuable 
remedy in many of these cases. There are burn- 
ing, stitching pains in the chest with short and op- 



PLEURODYNIA. 313 



pressed breathing; they are made worse by mov- 
ing, stooping, inspiration or touch, and are accom- 
panied by a sensation of tightness and pressure 
across the lower part of the chest and are aggra- 
vated by changes in the temperature. 

Cimicifuga: — In cases of pleurodynia which is 
worse upon the left side; in nervous, hysterical 
women who are rheumatic and subject to uterine 
diseases of a rheumatic or neuralgic character; the 
pains are worse from motion, extorting screams at 
times. 

Bryonia alba: — This remedy should be studied 
when the pains are sharp and stitching and worse 
from the slightest motion. The patient does not 
want to move but may be obliged to, from the 
severity of the pains. There is loss of appetite, a 
white tongue, dry mouth and great thirst; the 
bowels are constipated, the stools are brown as if 
burnt, and the breath is short and catchy, due to 
the stitching pains. 

Arnica montana: — When the pains appear as the 
result of over-exertion, the chest feeling sore as if 
bruised. 

Guaicum: — When the pleurodynia accompanies 
tuberculosis. 

Aconitum: — When the attack is the result of 
exposure to a dry, cold wind. 

Ammonium muriaticum: — In from five to twenty- 
grain doses, repeated every three hours, this rem- 
edy is considered almost a specific by some. 



314 AFFECTIONS OF THE DIAPHRAGM. 

AFFECTIONS OF THE DIAPHRAGM. 

The diaphragm is so intimately associated with 
the lungs in respiration that it is well to briefly 
consider a few of its more common lesions. 

Paralysis : — This ma}^ occur as a result of diph- 
theria, lead poisoning, hemorrhages into the cord, 
injuries, pressure from tumors about the origin of 
the phrenic nerve, and in acute ascending paralysis. 

The first symptoms observed in many of these 
cases are the reversed movement of the epigastrium 
and hypochondria during respiration; instead of 
bulging during inspiration they recede, and the ab- 
dominal viscera is not forced downward. All of 
those acts that demand a descent of the diaphragm 
are interfered with, as coughing, sneezing, defeca- 
tion, and the commencement of urination. 

The diagnosis is based upon the above symp- 
toms. The prognosis in all cases is grave. Re- 
covery is rare except in cases of diphtheria, in 
which recovery usually occurs, especially if there is 
collapse of the lower lobe of only one lung, but if 
the bases of both lungs are collapsed the prognosis 
is not good. The treatment of many of these cases 
is not satisfactory; its success depends upon the 
nature of the primary lesion. Artificial respirations 
employed for ten minutes every three or four hours 
may assist many of these cases. Stimulants in the 
form of hypodermic injections of ether or brandy 
are helpful. Coughing may be assisted b}^ support- 
ing the affected side. By lying upon the healthy 
side the expansion of the collapsed lung is facili- 
tated when one' lung is involved. In severe cases 
the constant inhalations of oxygen will be found of 



AFFECTIONS OF THE DIAPHRAGM. 315 

service. It should be warmed by passing through 
a metal coil kept in hot water. 

Spasms : — These may arise as the result of 
reflex or direct irritation of the diaphragm or 
of a lesion of the phrenic nerve. They may be 
clonic or tonic in character; hiccough is the most 
frequent manifestation of the former, and results 
from a sudden descent of the diaphragm, which 
causes an inrush of air through the dilated glottis. 
The tonic spasms may result from str3^chnia, exces- 
sive laughter, and hydrophobia. 

Displacements of the Diaphragm: — These may 
result either from a pressure from the thorax, 
which produces a downward displacement; or from 
the abdomen which gives rise to an upward dis- 
placement; the former results from disease of the 
pleura or pericardium, or from an enlarged heart, 
any of these by pressure causes a downward dis- 
placement. Upward displacement may result from 
contraction within the pleural cavity, collapse of 
a portion of a lung, or through any of the numer- 
ous pathological conditions which lead to enlarge- 
ment of the abdominal viscera, resulting in pressure 
upon the diaphragm, involving a whole or a part of 
the diaphragm. The symptoms may be those indi- 
cating the original disease rather than any disease 
confined to the diaphragm. In those cases where 
there is great distention of the abdomen there is a 
sense of tightness of the lower part of the chest 
caused by pressure on the diaphragm. Collapse of 
the lower portion of the lung may result from the 
continual pressure; when this occurs dyspnea is 
present. The collapse of a portion of the lung is 
indicated by the weak or absent breath sounds, a 



3l6 OSSEOUS COMPLICATIONS. 

diminished expansion of the lower lobes, and a re- 
ceding of the lower interspaces during inspiration. 
The treatment of these cases consists in the 
management of the original lesion. 



OSSEOUS COMPLICATIONS. 

In certain chronic pulmonary lesions, as bron- 
chiectasis, empyema, abscesses and pulmonary tuber- 
culosis there are changes of the bones and joints. 

Pulmonary osteo-arthropathy : — In this condition 
there appears an enlargement of the bones and 
joints, especially of the extremities, and a degree of 
stiffness of those parts, which become cold and 
covered with a clammy perspiration. There is little 
or no pain. 

The pathology of these cases is not determined. 
In a few, subperiostal thickening of the bone has 
taken place. In one case suffering from bron- 
chiectasis that came under the writer's observation, 
there was every evidence of enlargement of the 
bones. 

The diagnosis is based upon the presence of the 
enlargement of the bone, and stiffness of the joints 
without pain is observed in those suffering from a 
suppurative pulmonary lesion. 

It should be distinguished from acromegaly, 
osteo-arthritis, tubercular or syphilitic bone disease. 
The treatment is the management of the primary 
lesion. 

Clubbing of the fingers and toes, "digit hippo- 



OSSEOUS COMPLICATIONS. 317 

cratici": — This is occasionally met with in healthy 
people. It is frequently seen in cases of chronic 
pulmonary tuberculosis, bronchiectasis, chronic bron- 
chitis, emphysema, bronchial asthma and congenital 
heart disease. 

It usually appears slowly but may come on 
rapidly, and is accompanied with more or less pain. 
It is most commonly seen on the fingers; occasion- 
ally the toes are involved, but to a less degree. 

The terminal phalanges are much enlarged and 
clubbed. The nails curve over toward the palmar 
surface. There is thickening and enlargement of 
the pulp of the part but not of the bone. It is 
believed by Buhl to be due to a fibrous thickening 
of the rete mucosum. 

It may disappear with the relief of the disease 
causing it. 



CHAPTER XXXI. 
DISEASES OF THE BRONCHIAL GLANDS. 



These glands number from twelve to fifteen and 
are mostly found in the space formed by the bifur- 
cation of the trachea and along the main bronchi, 
where they are continuous with the smaller glands 
which lie in the interlobular connective tissue. 
They receive the lymph from the peribronchial, 
perivascular, and subpleural lymphatics, and com- 
municate above with the tracheal and esophageal 
glands. 

They are enlarged in a variety of diseases, and 
in those who have reached maturit}^ live in cities, 
or are exposed to air laden with dust they are of a 
deep black color. They are enlarged in whooping- 
cough, typhoid and scarlet fevers and in measles. 
In acute bronchitis they are hyperemic and swollen, 
while in chronic bronchitis they are indurated and 
show deep pigmentations. In pneumonia and bron- 
cho-pneumonia they are enlarged. If this enlarge- 
ment is marked they are pale, while if the enlarge- 
ment is slight they are hyperemic. 

In gangrene of the lung they show involvement, 
also in mediastinal and other forms of new growth; 
in the latter they may be enlarged to such an ex- 
tent as to cause bronchial stenosis. They are also 
enlarged in the later stages of syphilis, in malignant 
and tubercular diseases of the abdomen, and in re- 
tro-peritoneal tissue when the glands in both supra 
clavicular fossae show enlargement. 



DISEASES OF THE BRONCHIAL GLANDS. 319 

Tuberculosis of the bronchial glands is frequently 
secondary to tuberculosis of the lungs, except in 
children, when the infection often takes place through 
the lymphatic system by means of the tonsils and 
intestinal mucous membranes, the lungs being in- 
volved secondarily. 

Pathology : — The first change noticed in these 
glands is that they are inflamed, swollen, soft, and 
of a pinkish tint; later they become of a grayish' 
color and may be studded with miliary tubercles, 
and show area of caseation or undergo softening. 

Symptoms: — The symptoms depend upon the 
degree of involvement of the glands. A cough is 
present in all well defined cases, varying in char- 
acter from a short hacking cough to one that is 
spasmodic and suggests whooping-cough. There 
may be pressure upon the recurrent laryngeal or 
the pneumo-gastric nerve, giving rise to spasms or 
paralysis of the abductor muscles of the larynx. 
Aphonia and hoarseness may result from the 
pressure, as well as acceleration or slowing of the 
heart's action. Should the pressure be upon the 
superior vena cava, there will be edema about 
the face and neck. When there is pressure upon 
the esophagus there is difficulty in swallowing, as 
well as dyspnea when the trachea is involved. 

An expectoration of a mucoid or purulent char- 
acter may be present; the latter ma}^ contain tuber- 
cle bacilli if due to the softening of a tubercular 
gland that has ruptured into a bronchus. Hemop- 
tysis, while common, is not profuse. Pain, while 
not a constant symptom, when present is referred 
to the fourth dorsal vertebra and the upper portion 
of the sternum. 



320 DISEASES OF THE BRONCHIAL GLANDS. 

Physical signs. Inspection: — This reveals the 
symptoms common to a case of tuberculosis. 

Palpation: — This does not give any definite 
information. 

Percussion: — In advanced cases at least this 
will outline dullness in the interscapular region, and 
should one of the main bronchi be nearly ob- 
literated a compensating emphysema may be 
noticed. 

Auscultation: — The breath sounds may be fee- 
ble over one lung if the bronchus is interfered with, 
while bronchial breathing and bronchophony may 
be heard over the interscapular region. 

Diagnosis: — This is based upon the symptoms 
and physical signs outlined. 

Prognosis : — This is not good. Cases have been 
known to be arrested and recovery take place, yet 
they usually lead on to a general miliary tubercu- 
losis, or they may soften and form abscesses, per- 
forate a bronchus, and give rise to septic bronciio- 
pneumonia. 

Treatment : — The treatment of the tubercular 
glands should be along the same line as general 
tuberculosis, while those cases that are the result 
of syphilis demand treatment for the relief of that 
disease. One of the following remedies is fre- 
quently indicated in tubercular cases. 

Barium: — The various preparations of this drug 
are often of service when there is a defective 
mental and physical growth with a catarrhal condi- 
tion about the respiratory passages, in scrofulous 
individuals, with swelling and induration of the 
glands. The muriate where there is stony hardness 
of the enlarged glands with a constitutional tendency 



DISEASES OF THE BRONCHIAL GLANDS. 32 1 

to hemorrhage; the carbonate in light-haired child- 
ren with the pathological change most marked in 
the nares and throat, while the iodide is indicated 
by dark hair with greater involvement of the cervi- 
cal glands. 

lodium: — This is a great remedy in the scroful- 
ous diathesis where there is an enormous appetite, 
the patient becomes weaker all the time, and feels 
relieved only while eating or but shortly afterward. 

Ferrum iodatum: — In those cases where there 
are indications calling for both iodine and iron 
this is of service. The appetite is poor, the food 
distresses the patient, the digestion and assimila- 
tion are not perfect. The patient is anemic, there 
is a history of scrofulous affections in the family, 
and there is scrofulous enlargement of the glands. 
If the patient is a girl about the period of puberty 
amenorrhea with chlorosis and leucorrhea are apt 
to be present. 

Calcarea carbonica: — This remedy is frequently 
indicated in the phlegmatic form of this class of 
patients; they are slow and sluggish, the abdomen 
is large, the upper lip is prominent, and the fon- 
tanelles are slow in closing. The bowels are con- 
stipated and the stools chalky. As a child the 
patient was slow in learning to walk and cut his 
teeth slowdy, the extremities, especially the feet, 
are cold and sweaty. 



32 2 TUMORS OF THE MEDIASTINUM. 

TUMORS OF THE MEDIASTINUM. 

All forms of tumors are found here, the carci- 
noma more frequently than the sarcoma. The 
anterior mediastinum is their most frequent 
site. The rig-ht side is more often affected than 
the left. The majority of cases reported have ap- 
peared before the fortieth year. .They are more 
common in males than in females. They may 
arise from the connective tissue, lymph glands, 
epithelial structures of the trachea, bronchi, esoph- 
agus, or the periosteum. 

Pathology : — The sarcoma usually forms large 
tumors that may occupy a greater part of the 
thorax, and involves the trachea, main bronchi, 
pleura, blood vessels, and pericardium. The carci- 
noma forms smaller nodules that early undergo 
ulceration, giving rise to inflammation of the lung 
and frequently to gangrene. 

Synipto?7is : — As these growths develop slowly 
the symptoms appear gradually and are modified 
by the structure first involved. Cough is usually 
an early symptom. It may be paroxysmal in 
character and dependent on the pressure upon the 
trachea and bronchi. An expectoration soon ap- 
pears that varies in character from a mucoid ma- 
terial to a prune juice, to the fetid expectoration 
of bronchiectasis, or to that indicating gangrene. 
The pleura may be early involved and a pleural 
effusion result. The veins about the heart are 
often oppressed and venous congestion results, 
giving rise to lividity of the face and at times of 
the arms and hands, which later become edematous. 



TUMORS OF THE MEDIASTINUM. 323 

Hemoptysis is present at some period in nearly 
all cases. 

As the growth develops it presses upon the 
trachea and bronchi and gives rise to severe 
dyspnea and stridor. Should the phrenic nerve be 
involved there will be spasms of the diaphragm. 
Fever, while not a constant symptom, is usually 
present, and assumes the hectic type late in the 
disease. There is more or less emaciation' with 
anemia, loss of appetite, and other indications 
of chronic diseases. The cancerous cachexia may 
not be as pronounced as when the disease is 
primary in other organs. The effects of pressure 
will vary accordingly as the growth is in the 
anterior, middle, or posterior mediastinum. 

Physical signs: — Inspection. Most careful in- 
spection of the face and neck should be made in 
order to detect any appearance of lividity, con- 
gestion, edema, engorgement of the veins of the 
chest, or enlargement of the lymphatic glands. 
The shape of the chest should be observed and 
the absence of respiratory movements noted. 

Palpation: — The apex beat of the heart should 
be definitely located. The liver may be palpable 
below the costal margin, while the vocal fremitus 
may be diminished, lost, or increased, according 
to the part palpated. 

Percussion — Should the growth be in contact 
with the chest wall the note will be fiat, while 
any modification of the note may be obtained over 
the chest should the growth press upon the 
trachea, or bronchi. 

Auscultation: — The information gained by 
auscultation depends wholly upon the location of 



324 TUxMORS OF THE MEDIASTINUM. 

the growth. If it is in such a position that it 
presses upon a bronchus the respiratory sound may 
be enfeebled, absent, or rales of different intensity 
may be present; later, as softening takes place, 
cavernous breathing may be heard. 

Diagnosis: — This is difficult as the symptoms 
are not characteristic and are frequently mistaken 
for those of phthisis, bronchiectasis, chronic pneu- 
monia, effusion into the pleural cavities or peri- 
cardium, as well as aneurysm, syphilis, and dis- 
eases of the contiguous organs. In the majority 
of cases the diagnosis is reached by exclusion or 
not at all. 

Prop^nosis : — These cases are fatal. The course 
of the disease may be broken by periods of relief 
from many of the symptoms. The average dura- 
tion of the disease is from nine to twelve months. 

Treatment : — This is not satisfactory, and the 
symptoms must be met as they arise. It is well 
to remember that syphilitic gumma develops here 
as elsewhere, and in cases of constitutional 
syphilis treatment to that end may be of service. 
Arsenic is about the only remedy that has pro- 
duced much influence upon sarcoma, and those 
were of the skin. Paracentesis may be demanded 
in cases where effusion has taken place in the 
pleura. Tracheotomy or intubation may relieve 
the dyspnea but it should first be ascertained that 
the compression is above the point of incision, 
otherwise it may not accomplish much. 

Dermoid cysts: — These are among the rarer 
forms of intrathoracic tumors. They resemble 
ovarian dermoids in many particulars, and produce 
varied symptoms, many of which are the result of 



TUMORS OF THE MEDIASTINUM. 325 

pressure. At times they rupture into a bronchial 
tube, and observing the hair in the expectoration 
gives the first indication of their true nature. 

Abscesses of the mediastinum are most fre- 
quently the result of trauma, the infectious dis- 
eases, or tuberculosis. The symptoms in many 
cases are not definite, but there is usually pain,, 
which may be of a throbbing character, with 
fever, irregular chills and clammy sweats. In 
some cases they give rise to dyspnea, The pus 
may extend to the abdomen, discharge through 
the oesophagus or trachea, perforate the sternum, 
or become inspissated. At times the abscess may 
simulate an aneurysm but the bruit, diastolic shock 
and expansile character of the aneurysm are lack- 
ing. In cases of doubt a fine needle may be 
passed and the contents withdrawn, which will aid 
in distinguishing it from other conditions. 

The prognosis is grave, but depends upon the 
detection of the trouble and whether it can be 
removed or not. 

Cases of enlargement of the thymus and thy- 
roid glands as well as fibromata, lipoma, and hy- 
datid cysts have been observed. 

Emphysema of the mediastinum may result from 
trauma, whooping cough, diphtheria, and trache- 
otomy where there has been a division of the deep 
fascia. 



INDEX. 



Abscess of the lungs . 181 

in pneumonia 140 

of the mediastinum 325 

Acalypha indica in hemop- 
tysis ----. 126 

Acetic acid in fibrinous bron- 
chitis 79 

Acidum muriaticum in hypo- 
static hyperemia 176 

pulmonary tuberculosis.. 298 
Acidum sulphuricum in he- 
moptysis 127 

pulmonary tuberculosis.- 297 
Aconite in acute bronchitis of 

the larger tubes 46 

acute congestion of the 

lungs 165 

asthma 114 

chronic bronchitis . 68 

croupous pneumonia 156 

fibrinous bronchitis 80 

hemoptysis 124 

pleurisy .... 208 

pleurodynia 313 

Actinomycosis, pulmonary. _- 191 

definition 191 

diagnosis 192 

etiology 191 

pathology 191 

physical signs 192 

prognosis 192 

symptoms 191 

treatment 192 

^gophony 17 

Agaricin in pulmonary tuber- 
culosis 289 

Alcoholic stimulants in croup- 
ous pneumonia 154 

pulmonary tuberculosis.. 282 
Albuminuria in pulmonary 

bronchitis 278 

Ambra grisea in chronic bron- 
chitis 72 

Ambrosia artemisiefolia in 

hay asthma 119 

Ammonium carbonicum in 

edema of the lungs .-. 169 

nitrite in croupous pneu- 
monia 162 

Amyl nitrite in asthma, .-110-111 

croupous pneumonia 162 

vesicular emphysema .... 99 



Ammonium muriaticum in 

chronic bron chitis 67 

pleurodynia 313 

Anemia, pulmonary 197 

Anorexia in pulmonary tuber- 
culosis 274 

Anthracosis 188 

Antimonium arsenicum in 
acute bronchitis of the 

smaller tubes 57 

bronchopneumonia 136 

vesicular emphysema 99 

asthma 111 

Antimonium iodatum in acute 
bronchitis of the larger 

tubes - 50 

broncho pneumonia 136 

chronic bronchitis 65 

pulmonary tuberculosis.. 297 
Antimonium tartaricum, see 
tartar emetic. 

Apical pneumonia 146 

Apis mellifica in sero-fibrinous 

pleurisy 216 

Apoplexy, pulmonary 179 

Apomorphia in asthma 109 

Arnica in hemothorax 245 

Arnica montana in pleuro- 
dynia 313 

Arsenicum album in hemo- 
thorax 245 

Arsenicum album in acute 
bronchitis of the larger 

tubes 49 

acute pulmonary tubercu- 
losis 307 

asthma. Ill 

broncho-pneumonia 135 

chronic bronchitis 75 

edema of the lungs 169 

empyema 234 

gangi'ene of the lungs 187 

hypostatic hyperemia 176 

pulmonary tuberculosis-. 296 
serofibrinous pleurisy --. 216 

vesicular emphysema 99 

Arsenicum iodatum in acute 

pulmonary tuberculosis 307 

chronic bronchitis 74 

chronic pleurisy 226 

hay astlmia 119 

vesicular emphysema 99 



327 



328 



INDEX. 



Arseniate of antimony in 
asthma. 

Asclepias tuberosa in sero- 
fibrinous pleurisy 216 

Aspidosperma quebracho in 

vesicular emphysema 99 

P' Aspidospermine in asthma. 115 

Asthma 103 

definition .-_ 103 

diagnosis 106 

diet in 109 

etiology.. 103 

forms of 103-116 

pathology 104 

physical signs 106 

prognosis.- 107 

symptoms 105 

treatment 107 

Auscultation 14 

Atelectasis 88 

definition 88 

diagnosis 90 

etiology 89 

pathology _ 89 

physical signs 90 

prognosis .._ 90 

symptoms 89 

treatment 91 

Aurum arsenicosum in asthma 113 

Balsam of peru in abscesses of 

the lungs _ 183 

chronic bronchitis . 68 

Baptisia tinctoria in acute 

pulmonary tuberculosis 307 

pulmonary tuberculosis.. 297 

Baths in pulmonary tubercu- 
losis ... 281 

croupous pneumonia 153 

Barrel chest 5 

in vesicular emphysema . . 94 

Belladonna in acute bron- 
chitis of the larger tubes. . _ 46 
acute bronchitis of the 

smaller tubes 55 

acute congestion of the 

lungs 65 

fibrinous bronchitis 80 

Benzoic acid in chronic bron- 
chitis 73 

Baryta in diseases of the bron- 
chial glands _ 320 

Breathing : 

amphoric 15 

bronchial 15 

catchy 8 

cavernous 15 

Cheyne-Stokes 7 

correct 28 

costal 30 



Breathing — Continued. 

diaphragmatic 30 

difficult 7 

exercises in 30, 98 

high pitched 8 

in broncho-pneumonia.-- 131 
i n pulmonary tubercu- 
losis 283 

irregular... 8 

normal 15 

rapid 7 

shallow .- 8 

tracheal - - . 15 

vesicular-normal 15 

Bromium in asthma 114 

in fibrinous bronchitis... 79 

Bronchial flukes 102 

Bronchiectasis 83 

cavities in — how differing 

from tubercular 85 

definition 83 

diagnosis 85 

differentiation from 

pulmonary tuberculosis 271 

pulmonary gangrene . . 86 

etiology 83 

pathology 83 

physical signs 84 

prognosis 86 

symptoms - _ 84 

treatment - 86 

Bronchitis, 

acute — of the larger tubes . 40 

definition ... 40 

diagnosis 44 

differentiation from acute 

miliary tuberculosis _ . . 44 

etiology 40 

pathology- 41 

physical signs 42 

prognosis 44 

symptoms... 41 

synonyms 40 

treatment 45 

acute — of the smaller tubes 51 

definition 51 

diagnosis 53 

differentiation from mili- 
ary tuberculosis 53 

etiology 51 

pathology 51 

physical signs _. 52 

prognosis 54 

symptoms. 52 

synonyms 51 

treatment 54 

chronic . 59 

complications and s e - 

quelse 61 



INDEX, 



329 



Bronchitis — Continued. 

definition 59 

diagnosis - - - 61 

differentiation from in- 
terstitial pneumonitis. . 62 
from pulmonary tuber- 
culosis 62 

etiology 59 

inhalations in 64 

manual compression in.. 64 

pathology 59 

physical signs 60 

prognosis 62 

symptoms .. 59 

treatment 62 

capillary 51 

croupous 76 

drv 61 

fetid 61 

fibrinous..--- 76 

complications and se- 
quelae 78 

definition . 76 

diagnosis-. 78 

etiology 76 

pathology 76 

physical signs 77 

prognosis 78 

symptoms 1 77 

synonyms 76 

treatment 78 

mucous 76 

plastic 76 

Broncho-pneumonia 128-300 

definition 128 

diagnosis 132 

etiology 128 

pathology 129 

physical signs 131 

prognosis 132 

synonyms 128 

symptoms 130-131 

treatment 132 

Bronchophony 17 

Bronchorrhea 61 

Bryonia in acute bronchitis of 

the larger tubes 47 

asthma 114 

chronic bronchitis 68 

croupous pneumonia 157 

broncho-pneumonia 135 

pleurodynia 313 

pleurisy 206 

serofibrinous pleurisy 216 

Cactus grandiflorus in hemop- 
tysis 127 

Caffeinum in acute bronchitis 
of the smaller tubes 58 



Calcarea carbonica in chronic 

bronchitis 73-99 

diseases of the bronchial 

glands 321 

empyema . 234 

pulmonary tuberculosis.. 292 
Calcarea hvpophos in pulmon- 
ary tuberculosis 288-306 

Calendula in hemothorax 245 

Calicosis in pneumokoniosis.- 188 
Camphoric acid in pulmonary 

tuberculosis __. 289 

Cantharis in sero-fibrinous 

pleurisy 215 

Carbo regetabilis in chronic 

bronchitis 69 

croupous pneumonia 159 

Cardiac asthma 103 

Catarrh— chronic— varieties of 61 
Chelidonium majus in chronic 

bronchitis 71 

croupous pneumonia 157 

Cheyne- Stokes breathing ...7-132 
China in gangrene of lungs ._ 187 

hemothorax 245 

Chininum arsenicosum in 
acute pulmonary tubercu- 
losis 1 307 

hay asthma . - 120 

Chloral hydrate in asthma.-. 110 
spasm of the bronchus ... 82 

Chloroform in asthma 111 

Chylothorax 247 

definition 247 

diagnosis 248 

etiology . 247 

pathology 248 

physical signs 248 

prognosis 248 

symptoms 248 

synonyms 247 

treatment 249 

Cimicif uga in pleurodynia ... 313 

Climate in chronic pleurisy. - 225 

best adapted to chronic 

bronchitis 63 

pulmonary tuberculosis-. 284 
Clinical examination of the 

patient and semeiology 3 

Clothing in pulmonary tuber- 
culosis - 280 

Clubbing of fingers and toes. 316 
Coca ery throxylon in vesicular 

emphysema 99 

Codeinum in acute bronchitis 

of the larger tubes 50 

Cod liver oil in chronic bron- 
chitis - . - 63 

pulmonary tuberculosis-. 281 



330 



INDEX. 



Coffee in asthma 110 

Colchicuni in sero-fibrinous 

pleurisy 216 

Cold applications in hemop- 
tysis 124 

Color and condition of the 
cutaneous surface in pulmo 

nary diseases 264 

Complications in bronchiec- 
tasis . - 85 

pulmonary tuberculosis. . 272 
and sequelae in acute 
bronchitis of the larger 

tubes 44 

acute bronchitis of the 

smaller tubes 53 

bronchopneumonia 131 

chronic bronchitis 61 

croupous pneumonia 147 

fibrinous bronchitis 78 

sero-fibrinous pleurisy. 214 
vesicular emphysema.. 95 

Concretions, bronchial 102 

Consumption 251 

Copaiva in chronic bronchitis 68 
Costal type of breathing in 

therapeutics 30 

Cough in pulmonary tuber- 
culosis 259 

Coughing in pathology 260 

Cuprum in asthmta.. 115 

Cuprum arsenicosum in 

asthma 112 

Cyanosis in atelectasis 90 

broncho-pneumonia 131 

croupous pneumonia 155 

Cysts — dermoid 324 

Deep breathing in asthm.a 109 

pleurisy 204 

Dermoid cysts in tumors of the 

mediastinum 324 

Diaphragm — affections of 314 

paralysis of 314 

diagnosis 314 

symptoms.. . 315 

treatment 316 

Diaphragmatic breathing in 

therapeutics 30 

Diaphragmatic movements ._ 8 
Diarrhea in pulmonary tu- 
berculosis 263-278-287 

Differential diagnosis be- 
tween acute bronchitis and 
acute miliary tuberculosis 44 
acute congestion and 

pneumonia 164 

capillary bronchitis and 
miliary tuberculosis . . _ 53 



Differential diagnosis be- 
tween chronic bronchitis 
and interstitial pneumonitis 62 
chronic bronchitis and 

pulmonary tuberculosis 62 
emphysema and pleural 

effusion 96 

hemoptysis and hemate- 

mesis 123 

emphysema and pneumo- 
thorax 96 

pleurisy and intercostal 

neuralgia 20'> 

pulmonary infarction and 

catarrhal pneumonia . . 180 
pulmonary infarction and 

croupous pneumonia.. 180 
pulmonary gangrene and 

bronchiectasis 86 

tubercular cavities and 

bronchiectic cavities .. 85 
pleurodynia and inter- 
costal neuralgia 312 

and pleurisy 312 

and pericarditis 312 

pneumonia croupous and 

edema of the lungs 150 

catarrhal pneumonia.. 150 
hypostatic congestion.- 151 
pulmonary infarction.. 151 
pulmonary tuberculosis 151 
pneumothorax and pul- 
monary cavity 240 

pleural effusion 240 

diaphragmatic hernia.- 240 

sub-phrenic abscess 240 

emphysema 240 

pulmonary tubercul o s i s 
and abscess of the 

lungs 271 

bronchiectasis 271 

bronchitis 62 

malarial fever 271 

pulmonary syphilis.. .. 271 
Diet in acute bronchitis of 

the larger tubes 45 

acute bronchitis of the 

smaller tubes.. 54 

congestion of the lungs.. 165 

asthma 109 

broncho - pneumonia 134 

chronic pleurisy 225 

croupous pneumonia .154, 162 

empyema 230 

hay asthma 118 

pleurisy 206 

pneumothorax 243 

pulmonary tuberculosis.. 281 
Digit hippocratici 317 



INDEX. 



Digitalis in acute congestion 

of the lungs 166 

hemoptysis - 126 

vesicular emphysema 99 

Displacement of the d i a - 

phragm 315 

Drosera in chronic bronchitis 74 
Dyspnea : 

causes of 8, 24 

definition 7 

pathology _■ 24 

diseases accompanied bv- 24 

effects of.. "-- 25 

how produced 7 

in anasarca 246 

aneurysm 107 

acute bronchitis 42-52 

broncho, pneumonia 131 

cardiac asthma 107 

fibrinous bronchitis 77 

paralysis of diaphragm. 107 

pulmonary disease 7 

tuberculosis 276 

tracheal stenosis. 106 

Echinococcus 193 

Echinacea augustifolia in em- 
pyema 235 

Elaterium in edema of the 

lungs 169 

Electricity in pulmonary 

tuberculosis .-- 286 

Emaciation in pulmonary 

tuberculosis 263 

Emphysema : 

follows bronchitis 59 

in croupous pneumonia.. 154 
interstitial or interlobular 101 

definition 101 

etiology 101 

pathology 101 

symptoms 101 

treatment 101 

of the neck 101 

senile 100 

vesicular 92 

complications and se- 
quelae 95 

definition 92 

differentiation from 

pleural effusion 96 

from pneumothorax . 96 

diagnosis 96 

etiology r^ 92 

pathology 92 

physical signs 94 

prognosis ..: -. 97 

symptoms 93 

treatment - 97 



Empyema 227 

definition 227 

diagnosis ... 230 

etiology 227 

pathology 228 

pulsating -.— 230 

physical signs 229 

prognosis 230 

symptoms 228 

svnonyms 227 

treatment 230 

Endocarditis in pneumonia . . 

148-152 

Ergotinine. Tanret's, in hem- 
optysis 127 

Eriodictyon californicum in 
acute bronchitis of the 

larger tubes 50 

Eruptions and scars in pul- 
monary diseases 4 

Erythoxylon coca in vesicu- , 

lar emphysema 99 

Ether in asthma 110 

Ethyl iodide in asthma 113 

Eucalyptus in chronic bron- 
chitis 67 

Examination of the patient — 

semeiology 3 

Exercise in pulmonary tuber- 
culosis 284 

Expectoration in pulmonary 

tuberculosis 276 

destruction of 279 

Ferrum in hemoptysis 125 

Ferrum iodatum in diseases 

of the bronchial glands 321 

Ferrum phosphoricum in 
acute bronchitis of the 

larger tubes 47 

acute bronchitis of the 

smaller tubes 56 

acute congestion of the 

lungs 165 

acute pulmonarv tubercu- 
losis.. \ 306 

broncho-pneumonia 134 

croupous pneumonia 156 

Fever — hay 116 

lung 138 

Fibrosis — pulmonary : 

definition 171 

diagnosis 173 

etiology 171 

pathology 172 

physical signs 173 

prognosis 173 

symptoms . 172 

synonyms 171 

treatment 174 



332 



INDEX. 



Fremitus 9 

Friction sounds.-- 19 

Funnel breast 5 

Galloping consumption 302 

Gelsemium in acute bronchi- 
tis of the larger tubes 48 

broncho-pneumonia 134 

Geranium maculatum in hem- 
optysis 125 

Glands— bronchial : d i s e a s es 

of the 318 

diagnosis 320 

etiology --- .-. 318 

pathology- -. 319 

physical signs 320 

prognosis 320 

symptoms 319 

treatment 320 

Glonoinum in asthma --_ 110 

croupous pneumonia 162 

vesicular emphysema 99 

Glandular enlargement i n 

pulmonary disease 4 

Glycerin in fibrinous bronchi- 
tis 78 

in pulmonary tuberculo- 
sis 282 

Great altitudes in hay asthma 117 
Grindelia robusta in 

acute bronchitis of the 

larger tubes 50 

asthma 113 

chronic bronchitis 70 

Guaiacol in acute pulmonary 

tuberculosis 307 

Guaiacum in pleurodynia 313 

Hamamelis in hemoptysis 125 

in hemothorax 245 

Hay asthma--- 116 

definition 116 

diagnosis 117 

etiology--. 116 

prognosis 117 

symptoms 116 

treatment 117 

Heart in pneumonia 160 

Hemoptysis 121 

definition 121 

diagnosis 123 

differentiation from hem- 

atemesis 123 

etiology 121 

pathology 121 

prognosis- 123 

pseudo 121 

symptoms 122 

synonyms 121 

treatment 123 



Hemorrhage, broncho-pulmo- 
nary .. 121 

Hemorrhage in pulmonary 

tuberculosis 289 

Hemothorax 244 

definition 244 

diagnosis - 244 

etiology 244 

pathology 244 

physical signs .. - -.- 244 

prognosis 245 

symptoms . - - 244 

treatment 245 

Hepar sulphur in acute bron- 
chitis of the larger tubes 49 

acute tracheitis 35 

chronic bronchitis 72 

chronic pleurisy 226 

croupous pneumonia 159 

empyema. 234 

High pitclied stridulous 

breathing 8 

Hydrastis canadensis in hem- 
optysis .- 126 

Hydrothorax 245 

definition 245 

diagnosis 247 

etiology 245 

pathology 246 

physical signs 246 

prognosis 247 

symptoms 246 

synonym 245 

treatment 247 

Hydro-pneumothorax 242 

Hygienic surroundings in pul- 
monary tuberculosis 282 

Hyoscyamus in acute bron- 
chitis of the larger tubes. .. 49 

in chronic bronchitis 72 

Hyperpyrexia in pneumonia. 147 
Hypophosphite of lime in 
acute pulmonary tubercu- 
losis 306 

of soda in acute pulmon- 
ary tuberculosis 306 

Hyperemia, hypostatic 175 

definition 175 

diagnosis 175 

etiology. 175 

pathology 175 

prognosis 175 

symptoms 175 

synonyms 175 

treatment 175 

mechanical.. 177 

passive : 

definition — 177 

diagnosis.. — 178 



INDEX. 



333 



Hyperemia, passive — Cont'd. 

etiology 177 

pathology 177 

prognosis 178 

symptoms 177 

synonyms 177 

treatment - 178 

pathology 177 

etiology 177 

Hypostatic pneumonia 175 

Infarction, pulmonary 179 

definition 179 

diagnosis 180 

differentiation from ca- 
tarrhal pneumonia 180 

etiology 179 

pathology 179 

prognosis 180 

symptoms 1 79 

synonyms 179 

treatment 180 

Influenza 196 

Inhalations of creosote in ab- 
scess of the lungs 183 

in bronchiectasis 87 

oxygen in croupous pneu- 
monia - - - 155 

oxygen in edema of the 

lungs 169 

vapor in bronchiectasis . . 86 
in gangrene of the lungs 187 
in pulmonary tubercu- 
losis 299 

Interstitial or lobular emphy- 
sema - 101 

Inter-tracheal injections in 

bronchiectasis 88 

Iodide of ethyl in asthma 113 

lodium in chronic bronchitis 64 

chronic pleurisy 226 

croupous pneumonia 160 

diseases of the bronchial 

glands 321 

fibrinous bronchitis 79 

pulmonary tuberculosis-. 296 
Ipecacuanha in acute bron- 
chitis of the smaller tubes- 57 

chronic bronchitis 70 

asthma ._ 114 

hemoptysis 125 

Irritation in pathology 22 

Iodoform in tuberculosis 307 

Jaundice in pulmonary dis- 
ease 4 

Kali bichromicum in chronic 

bronchitis _ 65 

fibrinous bronchitis 78 

syphilis of the lungs 202 



Kali carbonicum in chronic 

pleurisy 226 

pleurisy 207 

pulmonary tuberculosis.- 295 

Kali iodatum in asthma 112 

chronic bronchitis 74 

edema of the lungs 169 

pulmonary tuberculosis.. 295 

Kali nitricum in asthma 110 

croupous pneumonia 162 

Lachesis in acute bronchitis 

of the smaller tubes 57 

Lactuca virosa in chronic 

bronchitis . . - 73 

Laurocerasus in acute bron- 
chitis of the smaller tubes. 57 

Liniment in asthma 111 

Lobar pneumonia 138, 300 

Lobelia inflata in asthma 109 

vesicular emphysema 98 

Lungs, the: 

description 1 

of what composed 21 

abscess of 181 

definition 181 

diagnosis." 183 

etiology 181 

pathology - 181 

physical signs 182 

prognosis 183 

symptoms 182 

treatment 183 

acute congestion of 163 

definition 163 

diagnosis 164 

etiology 163 

pathology 163 

physical signs 164 

prognosis 164 

symptoms 163 

synonyms 163 

treatment 164 

cirrhosis of .. 171 

edema of 166 

definition 166 

diagnosis 168 

etiology 166 

pathology 167 

physical signs 167 

prognosis 168 

symptoms 167 

treatment 168 

fever 138 

gangrene of 140, 184 

definition 184 

diagnosis 186 

etiology 184 

pathology 184 

physical signs 185 



334 



INDEX. 






Lungs, gangrene of — Continued. 

prognosis.-- .-- 186 

symptoms - . . 185 

treatment 186 

hydatids of 193 

definition 193 

diagnosis - 194 

etiology 193 

pathology 193 

physical signs -- _ 194 

prognosis 194 

symptoms .-. 193 

treatment 194 

tumors of 197 

diagnosis 198 

etiology 197 

pathology _ 197 

physical signs 198 

prognosis 198 

symptoms 198 

treatment 199 

stones - 102 

syphilis of : 

diagnosis 201 

pathology .. 200 

physical signs 201 

prognosis 201 

symptoms 200 

treatment 202 

Lycopodium in acute bron- 
chitis of the smaller tubes. - 56 

broncho-pneumonia 135 

chronic bronchitis 69 

lithemia 99 

croupous pneumonia 1 58 

pulmonary tuberculosis-- 294 
Manual compression in 

chronic bronchitis 64 

Mediastinum: 

abscesses of the 325 

emphysema of 325 

tumors of 324 

diagnosis 324 

pathology - - _ 322 

physical signs 323 

prognosis 324 

symptoms 322 

treatment 324 

Mensuration 20 

Mercurius in acute bronchitis 

of the larger tubes 46 

croupous pneumonia 159 

Mercurius dulcis in syphilis 

of the lungs 202 

Mercurius iodatus flavus (yel- 
low iodide) in chronic bron- 
chitis 73 



Mercurius solubilis in 

acute tracheitis 35 

broncho-pneumonia 136 

Metallic tinkling ' 19 

Millefolium in hemoptysis ... 125 
Millers' phthisis in pneumo- 

koniosis 188 

Morphium sulphuricum in 

asthma 110 

Moschus in asthma 114 

Mycosis — pulmonary : 

definition - . - 195 

diagnosis 196 

etiology 195 

pathology - 195 

physical signs 195 

prognosis - 196 

symptoms 195 

synonyms 195 

treatment.-- 196 

Naphthalinum in hay asthma 119 

vesicular emphysema 99 

Natrum iodatum in syphilis 

of the lungs 202 

Night sweats in pulmonary 

tuberculosis 288 

Nitrate of potash in asthma.- 110 

croupous pneumonia 162 

Nitrate of soda in asthma 110 

croupous pneumonia 162 

Nitricum acidum in pulmon- 
ary tuberculosis - 298 

syphilis of the lungs 202 

Nitro glycerin in bronchial 

stenosis 82 

Noxious material in hay 

asthma 118 

Nux vomica in acute bron- 
chitis of the larger tubes. -. 47 

asthma 112 

pulmonary tuberculosis.- 299 

Opium in asthma 110 

Osseous complications - - 316 

diagnosis 316 

pathology 316 

treatment 316 

Osteo arthropathy, pulmonary 316 
Oxygen in broncho - pneu- 
monia 134 

croupous pneumonia .154-155 

pulmonary infarction 181 

Palpation — definition 9 

Pectoriloquy - - . 18 

Peptic asthma 104 

Pericarditis in pneumonia- -- 

--- --- 147, 152, 154 

distinguished from pleu- 
rodynia 312 

Percussion 10 



INDEX. 



335 



Phellandrium in chronic 

bronchitis _ 67 

Phosphoric acid in pulmonary 

tuberculosis 294 

Phosphorus in acute bron- 
chitis of the larger tubes. - . 48 
acute congestion of the 

lungs 165 

broncho pneumonia 135 

chronic bronchitis 70 

croupous pneumonia 157 

edema of the lungs 169 

fatty degeneration 99 

fibrinous bronchitis 80 

hemoptysis 126 

pulmonary tuberculosis-. 291 
Physical examin a t i o n in 

acute miliary tuberculosis. 305 
Phytolacca in syphilis of the 

lungs 202 

Phthisis. 251 

Picrotoxine in pulmonary 

tuberculosis 289 

Pigeon breast 5 

Pilocarpin in fibrinous bron- 
chitis 78 

Pleura : 

new growths of 249 

prognosis 250 

treatment 250 

dropsy of 245 

Pleurisy 203 

definition 203 

differentiation from 
intercostal neuralgia.. 205 
pulmonary tuberculosis 273 

Pleurisy — chronic 222 

definition 222 

diagnosis 223 

etiology _ 222 

pathology 222 

physical signs _ 223 

prognosis 224 

symptoms- . 223 

Pleurisy — chronic with effu- 
sion . . 224 

diagnosis 224 

etiology 224 

pathology 224 

physical signs 224 

prognosis 224 

symptoms 224 

treatment 225 

chronic dry 222 

chylous 247 

Pleurisy — diaphragmatic 219 

diagnosis 220 

definition 219 

etiology 219 



Pleurisy, diaphragmatic — Cont'd. 

physical signs 219 

prognosis 220 

symptoms 219 

treatment 220 

Pleurisy — fibrinous 203 

diagnosis 205 

etiology. 203 

pathology .._ 203 

physical signs 205 

prognosis 206 

symptoms 204 

synonyms 203 

treatment 206 

Pleurisy — sero- fibrinous 209 

definition 209 

diagnosis 214 

etiology 209 

pathology 209 

physical signs 212 

prognosis 214 

symptoms 210 

treatment 215 

purulent 227 

suppurative 227 

tubercular — see tubercular 

pleurisy. 221 

Pleurisy — in croupous pneu- 
monia 147 

Pleurodynia.. 311 

definition 311 

diagnosis 312 

distinguished from 

intercostal neuralgia - . 312 
pleurisy and pericardi- 

itis 312 

etiology.. 311 

pathology 311 

physical signs 311 

prognosis 312 

symptoms 311 

synonym 311 

treatment 312 

Pneumatic cabinet in vesicu- 
lar emphysema 98 

Pneumokoniosis 188 

definition 188 

diagnosis 1 90 

etiology. .. 188 

pathology 188 

physical signs 190 

prognosis 190 

symptoms 189 

synonyms 188 

treatment 190 

Pneumonia : 

abortive 146 

apical 146 

aspiration .-. 129 



336 



INDEX. 



Pneumonia — Con tinued. 

bilious 146 

catarrhal 128 

central 146 

croupous : 

definition 138 

diagnosis 148 

differentiation from 
edema of the lungs -- 150 
catarrhal pneumonia 150 
hypostatic congestion 151 
pulmonary infarction 151 

tuberculosis 151 

etiology 138 

pathology 188 

physical signs . 143 

prognosis 153 

symptoms 140 

synonyms 188 

treatment ._- 153 

typhoid _ 145 

double - - - - 152 

ephemeral 146 

fibrinous 138 

hypostatic 129, 175 

interstitial--. ...172, 199 

lobar 138, 300 

lobular- 128 

migratory 145 

secondary 148 

white -... .... 199 

in pulmonary tuberculosis 

273-277 

of infants _ 146 

stimulants in 155 

Pneumonitis 188 

Pneumothorax 236 

definition 236 

differentiation from pul- 
monary cavity 240 

pleural effusion 240 

diaphragmatic hernia-- 240 

subphrenic abscess 240 

emphysema 240 

diagnosis 239 

etiology 286 

in pulmonary tuberculosis 278 

pathology . .* 286 

physical signs 238 

prognosis 241 

symptoms 287 

treatment 241 

Prophylactic treatment in hay 

asthma 118 

Psorinum in asthma 113 

hay asthma 120 

empyema 235 

Pulmonary complications of 
acute disease - - 196 



Pulmonary gymnastics i n 

chronic pleurisy 225 

Pulsatilla in acute bronchitis 

of the larger tubes 48 

chronic bronchitis 66 

pulmonary tuberculosis.. 295 

Pulsating empyema 230 

Pyopneumothorax 242 

Quebracho in vesicular em- 
physema 99 

Rales 18 

Ranunculus bulbosus in pleu- 
rodynia --- 312 

Respiration — rapidity of 6 

slow 7 

Respiratory movements 6 

Rest in pulmonarv tubercu- 
losis - 284 

Rhachitic chest 5 

Rhus toxicodendron in hypo- 
static hyperemia 176 

serofibrinous pleurisy .. 216 
Rumex crispus in acute bron- 
chitis of the larger tubes 49 

chronic bronchitis 71 

pulmonary tuberculosis.. 298 
Sabal serrulata in chronic 

bronchitis 68 

Sabadilla in hay asthma 120 

pleurisy 207 

Sambucus nigra in asthma... 114 
Sanatorium treatment in pul- 
monary tuberculosis 290 

Sangainaria canadensis in 

acute tracheitis 84 

chronic bronchitis 71 

croupous pneumonia 158 

pulmonary tuberculosis.- 293 
Sarsaparilla in svphilis of the 

lung '. 202 

Scilla in broncho pneumonia. 186 

pleurisy 207 

Senega in chronic bronchitis. 65 

Senile emphysema 100 

Sepia in chronic bronchitis. . . 69 

Sequelae in hay asthma.. 117 

Shallow and irregular breath- 
ing 8 

Siderosis in pneumonoko- 

niosis- 188 

Sighing, shallow, breathing.. 6 
Silicea in chronic bronchitis. 72 

chronic pleurisy 226 

empyema 233 

pulmonary tuberculosis.- 293 
Sinapis nigra in hay asthma.. 119 

Size of the chest 4 

Sparteine in vesicular emphy- 
sema 99 



INDEX. 



337 



Spasmodic asthma 103 

Spasms of the diaphragm 315 

Splenozation 175 

Spongia tosta in acute trache- 
itis 35 

chroni c bronchitis 70 

fibrinous bronchitis 79 

Scilla in acute bronchitis of 

the larger tubes 50 

broncho pneumonia 136 

Secale in gangrene of lung... 187 

Sodium iodide in bronchial 
stenosis 82 

Stannum in pulmonary tuber- 
culosis 298 

Stannum iodatum in chronic 
bronchitis 65 

Static electricity in pulmon- 
ary tuberculosis - - . _ 286 

Stenosis — bronchial : 

definition 80 

diagnosis 81 

etiology 80 

pathology 80 

physical signs 81 

prognosis 82 

symptoms 81 

treatment 82 

Stenosis of the trachea 38 

definition 38 

etiology 38 

prognosis 38 

symptoms 38 

treatment 38 

Strychnium in : 

acute bronchitis of the 

smaller tubes 58 

vesicular emphysema 99 

broncho-pneumonia 134 

croupous pneumonia 155 

pulmonary infarction 180 

Strychnia ars. in asthma HI 

Succussion 20 

Sulpho-carbolate of soda in 
empyema 235 

Sulphur in 

asthma 113 

chronic bronchitis 66 

chronic pleurisy 225 

croupous pneumonia 160 

empyema 235 

pulmonary tuberculosis. _ 292 
serofibrinous pleurisy. .. 216 

Surgical treatment of empy- 
ema 231 

Syphilis, pulmonary, differen- 
tiation from pulmonary tu- 
berculosis 271 



Tartarus emeticus in acute 

congestion of the lungs 166 

acute bronchitis of the 

smaller tubes 56 

acute tracheitis 34 

bronchopneumonia 135 

chronic bronchitis 70 

croupous pneumonia 159 

edema of the lungs 169 

vesicular emphysema 99 

Therapeutics 27 

Thoracentesis in serofibrinous 

pleurisy 217 

Trachea, new growths of 37 

Trach eal diphtheria 36 

symptoms .-- 36 

Tracheal perforation _ 39 

Tracheal stenosis - - - 38 

Tracheal syphilis 37 

Tracheitis — acute 33 

diagnosis 33 

prognosis 33 

treatment 34 

Tracheit is — chronic 35 

diagnosis 36 

etiology 35 

pathology 35 

prognosis 36 

symptoms 35 

treatment 36 

Tubercular pleurisy - 221 

prognosis - 222 

treatment 222 

Tuberculin in pulmonary tu- 
berculosis - - - - 290 

Tuberculosis : 

acute miliary 300-304 

fibroid 308 

definition 308 

diagnosis 310 

etiology 308 

pathology 308 

physical signs 309 

prognosis 310 

symptoms 308 

treatment 310 

laryngeal 277 

pulmonary 251 

chronic ulcerative 251 

complications 272 

diagnosis 270 

differentiation from : 

bronchitis 62 

bronchiectasis 271 

abscess of lungs . . _ 271 

malarial fever 271 

pulmonary syphilis 271 

etiology 251 

symptoms 258 



338 



INDEX. 



Tuberculosis — Continued. 

prognosis . 275 

treatment 279 

incipient stage : 

physical signs of 267 

second stage: 

physical signs of 268 

third stage : 

physical signs of 269 

acute.-.. 300 

synonyms 300 

varieties : 

lobar pneumonia 300 

diagnosis 301 

broncho pneumonic 

form 302 

symptoms 303 

physical examina- 
tion 303 

diagnosis 304 

acute miliary tuber- 
culosis 304 



Tuberculosis — Continued. 

physical examina- 
tion _ 305 

prognosis 305 

treatment 305 

Tuberculosis of the trachea.. 37 

symptoms 37 

treatmjent 37 

Veratruni album in acute 
bronchitis of the smaller 

tubes - 57 

Veratrum viride in acute con- 
gestion of the lungs 165 

croupous pneumonia 155 

hemoptysis 125 

vesicular emphysema 98 

Vocal resonance 17 

Vomiting in pulmonary tu 

berculosis 288 

Whooping cough 196 



JUH 



19 



ym 



JUN. 19 1902 



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